Exhibit 10.1
First Amendment to
The MSA Agreement
Between Elevance Health, Inc. and American Well Corporation
This First Amendment (“Amendment”) dated and effective as of January 01, 2023 (“Amendment Effective Date”) is by and between Elevance Health, Inc., on behalf of itself and its Affiliates (“Elevance Health”) and American Well Corporation (“Supplier”) and amends that certain MSA Agreement between the parties dated January 01, 2023 (the “Master Agreement”).
RECITALS
WHEREAS, Anthem, Inc. changed its name to Elevance Health, Inc. on June 28, 2022; and
WHEREAS, the parties desire to amend the Master Agreement to update the contracting party names.
AGREEMENT
NOW, THEREFORE, in consideration of the mutual promises and undertakings described in this Amendment, the parties, intending to be legally bound, hereby agree to amend the Master Agreement as follows:
1. Conflict of Terms, Definitions. In the event of a conflict between the terms of this Amendment and the terms of the Master Agreement, the terms of this Amendment shall control. Unless otherwise specified in this Amendment, all capitalized terms shall have the meaning given to them in the Master Agreement.
2. Medicaid Exhibits. All States Medicaid Exhibits are added to the MSA with this Amendment.
3. No Other Modifications. Except as provided herein, the terms and conditions of the Master Agreement shall remain the same, in full force and effect.
IN WITNESS WHEREOF, the parties have caused this First Amendment to be duly executed as of the Amendment Effective Date indicated above.
American Well (“Supplier”) | Elevance Health, Inc. (“Elevance Health”)
|
s/o Bradford Gay | S/o Anar Pathak |
EXHIBIT “E”
STATE MEDICAID ATTACHMENTS
The following Exhibits are applicable to specific services performed by Supplier/Licensor for any member enrolled in a Medicaid Program in a particular state to which the Exhibit pertains. Notwithstanding the foregoing, the parties hereto acknowledge that (i) neither American Well nor Amwell Medical Group entities are health plans, as such, the parties hereto further acknowledge that all provisions contained in the Exhibits may not be applicable to certain services provided by Suppliers/Licensor as certain provisions are applicable solely to Providers of medical services. Only those provisions applicable to the specific services provided by Supplier/Licensor shall be deemed to be incorporated into the Agreement. State-specific regulatory requirements may be added/updated from time to time without need for additional amendment. American Well reserves the right, in its sole discretion, to terminate a State Medicaid Exhibit upon thirty (30) days written notice if such changes adversely impact American Well. In the following documents, “Subcontractor”, “Contractor” and “Vendor” refer to the “Supplier” or “Licensor” under the Agreement.
Exhibit E-1 Arkansas Medicaid Program Participant Exhibit (03.30.22)
Exhibit E-2 California Medicaid Subcontract Exhibit (10.20.22)
Exhibit E-3 Colorado Medicaid Subcontractor Exhibit (CCHA, LLC) (01.24.19) Exhibit E-4 Simply AHCA Florida Medicaid Subcontract Exhibit (04.11.22) Exhibit E-5 Simply FHK Florida Subcontract Exhibit (03.30.22)
Exhibit E-6 Georgia Medicaid Exhibit (08.10.2022)
Exhibit E-7 Medicaid Exhibit Indiana HHW HIP HCC (03.08.19) Exhibit E-8 Iowa Medicaid Participation Exhibit (07.19.21) Exhibit E-9 Medicaid Exhibit Kentucky (11.02.20)
Exhibit E-10 Medicaid Exhibit Louisiana (12.19.22)
Exhibit E-11 Medicaid Exhibit Maryland (10.4.2022)
Exhibit E-12 Minnesota Medicaid Subcontractor Exhibit (11.10.20) Exhibit E-13 Missouri State-Specific Requirements (06.03.20) Exhibit E-14 Nebraska State-Specific Requirements (06.17.20) Exhibit E-15 Medicaid Exhibit Nevada (11.09.22)
Exhibit E-16 New Jersey Medicaid Subcontract Exhibit (10.14.2022)
Exhibit E-17 New York HealthPlus (Empire) Subcontractor Exhibit (09.21.21) Exhibit E-18 New York Highmark of WNY Subcontractor Exhibit (09.21.21) Exhibit E-19 North Carolina Participation Exhibit and Requirements (10.21.21) Exhibit E-20 Ohio Regulatory Exhibit (12.13.21)
Exhibit E-21 Medicaid Exhibit South Carolina (05.31.22)
Exhibit E-22 Medicaid Exhibit Tennessee – Enrollee Contact (10.04.22) Exhibit E-23 Medicaid Exhibit Tennessee – No Enrollee Contact (10.04.22) Exhibit E-24 Medicaid Tennessee BAA – Utilize for all TN Vendors (09.18.20) Exhibit E-25 Medicaid Exhibit Texas (09.07.22)
Exhibit E-26 Virginia Medicaid Requirements (11.05.21)
Exhibit E-27 Medicaid Exhibit Washington (08.10.22)
Exhibit E-28 District of Columbia (DC) Specific Requirements (10.14.2022)
Exhibit E-29 West Virginia State Specific Requirements (12.19.22)
Exhibit E-30 Medicaid Exhibit Wisconsin (03.04.21)
EXHIBIT E-1
ARKANSAS MEDICAID PROGRAM PARTICIPATION EXHIBIT AND SPECIFIC
REQUIREMENTS
This Arkansas Medicaid Program Participation Exhibit and Specific Requirements (the “Regulatory Exhibit”) will supplement the Agreement (the “Agreement”) between APC PASSE, LLC d/b/a Summit Community Care (“Health Plan”) and Vendor (“Vendor”) effective upon approval and will run concurrently with the terms of the Agreement. This Regulatory Exhibit is limited to the terms and conditions governing the provision of services in the fulfillment of contractual responsibilities to the State of Arkansas (“State”) in the provision of health care services. The provisions set forth in this Regulatory Exhibit shall be deemed to be part of the Program Contract and are intended to comply with legislative and regulatory requirements of the State. To the extent that such laws and regulations are applicable and/or are not otherwise preempted by federal law, the provisions set forth in this Regulatory Exhibit shall apply. The provisions of this Regulatory Exhibit apply with respect to individuals who are enrolled in a Medicaid Program (hereinafter collectively referred to as “Medicaid Members”). These provisions shall also be incorporated into participating provider agreements whether by reference or as expressly set forth. Any clause that is deemed to conflict with the provision of the Agreement, Program Contract, state or federal law, this exhibit shall control for those Vendor services provided and are hereby incorporated into this Exhibit. Failure of Vendor to incorporate these provisions shall not relieve participating providers from compliance with applicable provisions.
Addendum A
Conflict Of Interest Addendum
= $200,000, third violation = $400,000).
EXHIBIT E-2
California Medi-Cal Managed Care Program
for Business Associate or Vendor
The Business Associate or Vendor agrees to comply with the following terms and conditions:
http://www.dhcs.ca.gov/formsandpubs/laws/priv/Pages/DHCSBusinessAssociates Only.aspx.
EXHIBIT E-3
COLORADO STATE-STATE SPECIFIC REQUIREMENTS CCHA, LLC
This Exhibit is attached to the agreement (the “Agreement”) between Anthem, Inc. (“Contractor”) and Center for the Study of Services (“Vendor”) on behalf of CCHA, LLC d/b/a Colorado Community Health Alliance (CCHA) and is incorporated into the Agreement.
RECITALS
As Center for the Study of Services and Anthem, Inc. are parties to that certain Agreement (“Subcontract”) and wish to addend said Subcontract as provided herein.
AGREEMENT
IN CONSIDERATION of the mutual promises set forth herein, in the Subcontract, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:
This Exhibit is limited to the terms and conditions governing the provision of services to or on behalf of CCHA, LLC d/b/a Colorado Community Health Alliance (CCHA) in the fulfillment of CCHA’s contractual responsibilities to the Colorado Department of Health Care Policy & Financing (“Department”), regarding all activities under the Accountable Care Collaborative (ACC) in regions 6 and 7 Regional Accountable Entity (RAE) Agreement (“Agreement”). This Exhibit will run concurrently with the terms of the Agreement.
For the purposes of this Exhibit:
The Subcontractor agrees to and agrees to fulfill, as the case may be, the following:
U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000.00 and not more than $100,000.00 for each such failure.
§8-17.5-102(5)(c), C.R.S., Subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this agreement or enter into a contract with a subcontractor that fails to certify to Subcontractor that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this agreement.
EXHIBIT E-4
MEDICAID SUBCONTRACTOR REQUIREMENTS ATTACHMENT
SMMC MEDICAID CONTRACT EFFECTIVE DECEMBER 1, 2018
This Medicaid subcontract regulatory addendum (“Addendum”) is attached to the Subcontract (the “Subcontract”) between Anthem, Inc. for or on behalf of its Affiliates (“Anthem”) and
(“Subcontractor”) and is incorporated into the Subcontract. To the extent any provisions herein conflict with the provisions set forth in the Subcontract, the provisions in this Addendum shall control. The provisions set are intended to comply with legislative and Regulatory Requirements of the State of Florida. For avoidance of doubt, the defined term “Subcontractor” is used in the Agreement as a term of art in this template solely to define a downstream contract of Anthem. The term Subcontractor does not mean that the Subcontractor is delegated by Anthem to perform a core Health Plan (defined below) function that may require approval from Anthem and Health Plan and/or AHCA (defined below).
ADDENDUM PROVISIONS
The provisions of this Medicaid Delegation Subcontract Addendum supersede any language to the contrary which may appear elsewhere in the Subcontract.
For the purposes of this Addendum, the following definitions shall apply:
“AHCA” shall mean the Florida Agency for Health Care Administration “DHHS” shall mean the United States Department of Health and Human Services. “DOEA” shall mean the Department of Elder Affairs.
“Health Plan” shall mean Simply Healthcare Plans, Inc. and/or its d/b/a Clear Health Alliance, as applicable.
“Member” shall mean any person who is an eligible program beneficiary and who is duly enrolled as Health Plan member in accordance with applicable enrollment requirements.
“Program” shall mean a Florida Medicaid Managed Care Program (“Medicaid”), a state or local Child Health Insurance Program (“CHIP”), or any successor programs thereto, and such other federal, state or local program related to, or administered in conjunction with, Medicaid or CHIP including, without limitation, any program providing coverage for eligible family members of CHIP beneficiaries. Program shall also include the State of Florida Medicaid Managed Long Term Care Program (the “LTC Program”) administered by AHCA.
“Program Contract” shall mean the contract(s) between AHCA and the Health Plan whereby the Health Plan has responsibilities regarding the provision of health care services to certain Florida Medicaid and Long Term Care members.
“Regulatory Requirements” shall mean any requirements imposed by applicable federal, state or local laws, rules, regulations, a Program Contract, or otherwise imposed by AHCA in connection with the operation of the Program or the performance required by either party under this Subcontract.
“Subcontract” shall mean the Subcontract as defined in the opening paragraph and any accompanying documents that set forth services provided by Health Plan and Subcontractor.
Subcontractor agrees to abide by all of the following specific terms:
a Identification of conditions and method of payment;
(120) days of the end of the year.
Subcontractor under the contract between Health Plan and Vendor. Documentation of the insolvency account, including account balances and governing agreements, shall be provided to AHCA upon request. Failure to establish a required insolvency account shall result in liquidated damages in accordance with Section XIV of the Medicaid Contract. If Health Plan fails to comply with the requirements of this section, Health Plan may be subject to sanctions pursuant to Sanction XIII, Sanctions, of
the Medicaid Contract, or liquidated damages pursuant to Section XIV, Liquidated Damages, of the Medicaid Contract, as determined by AHCA.
EXHIBIT E-5
FLORIDA HEALTHY KIDS SUBCONTRACTOR ADDENDUM
Supplemental Terms
EFFECTIVE JANUARY 1, 2020
It is FHK’s intention to provide Subcontractor with reasonable notice of any audit or inspection of Subcontractor by FHK and to conduct any such audits or inspections at reasonable times. Additionally, FHK, AHCA, AHCA’s Office of the Inspector General, HHS, CMS, HHS Office of the Inspector General, the Comptroller General of the United States or their designees, may at any time, inspect the premises, physical facilities, and equipment where work related to the Agreement and the FHK Contract is performed.
Subcontractor agrees to cooperate in any evaluative efforts conducted by FHK, FHK’s contractors, or authorized state or federal agencies during the FHK Contract term and for a period of at least ten
(10) years following the term of the FHK Contract. These efforts may include a post-FHK Contract audit. In the event records must be sent to FHK, Subcontractor is responsible for production, delivery and associated costs.
nor Simply may hold the Member liable for the remainder of the charges. Members shall remain responsible for any applicable Copayments. Subcontractor shall indemnify, defend and hold Members harmless from all financial loss caused by Subcontractor’s failure to comply with the FHK Contract or state or federal laws or regulations.
For non-emergency transportation provider drivers, Subcontractor shall perform, or ensure performance of, a criminal background screening comparable to a level 1 background screening, as approved by AHCA for Florida Medicaid non-emergency transportation providers.
U.S.C. § 1320a-7a; (iii) the Civil and Criminal False Claims Acts, 31 U.S.C. §§ 3729-3733; (iv) the Stark Law, 42 U.S.C. §1395nn; (v) the Health Care Fraud
Statute, 18 U.S.C. § 1347, Federal; and (f) to the extent applicable, the respective state law counterparts of any of the federal laws described in (i) through (v) above.
EXHIBIT E-6
GEORGIA REGULATORY EXHIBIT
PROVISIONS APPLICABLE TO GEORGIA COVERED INDIVIDUALS
This Georgia Regulatory Exhibit (the “Exhibit”) will supplement the Agreement (the “Agreement”) between AMGP Georgia Managed Care Company, Inc. d/b/a Amerigroup Community Care (“Amerigroup”) and Subcontractor (“Subcontractor”) effective upon approval and will run concurrently with the terms of the Agreement. This Exhibit is limited to the terms and conditions governing the provision of services in the fulfillment of contractual responsibilities to the state of Georgia in the provision of health care services. The provisions set forth in this Exhibit shall be deemed to be part of the Program Contract and are intended to comply with legislative and regulatory requirements of the State of Georgia. To the extent that such laws and regulations are applicable and/or are not otherwise preempted by federal law, the provisions set forth in this Exhibit shall apply. The provisions of this Exhibit apply with respect to services furnished under a Medicaid or CHIP program, including without limitation, for Medicaid services furnished under a program for dually eligible covered persons (hereinafter referred to as “Covered Persons”).
(a) Agency shall mean a federal, state or local agency, administration, board or other governing body responsible for the governance or administration of a Program. With respect to the operation of the Georgia Families Program, as used herein, Agency also means the Georgia Department of Community Health (“DCH”).
(b) Program shall mean a Georgia Medicaid managed care program (“Medicaid”), a state or local Children’s Health Insurance Program (“CHIP”), or any successor programs thereto, and such other federal, state or local program related to, or administered in conjunction with, Medicaid or CHIP including, without limitation, any program providing coverage for eligible family members of CHIP beneficiaries.
(c) Material Subcontractor shall mean a Subcontractor, excluding Providers, receiving Subcontractor payments from Amerigroup in amounts equal to or greater than ten (10) million dollars annually during the state fiscal year.
(d) Program Contract shall mean the contract between Amerigroup and an applicable party, such as an Agency or a Program beneficiary, which governs the delivery of managed health care services to Program beneficiaries.
(e) Regulatory Requirements shall mean any requirements imposed by applicable federal, state or local laws, rules, regulations, a Program Contract, or otherwise imposed by the Agency, acting within its jurisdiction in connection with the operation of the Program or the performance required by either party under this Exhibit.
(f) Subcontractor shall mean any third party who has a written contract with Amerigroup to perform a specified part of the Amerigroup’s obligations under the Program Contract.
(a) Discussing treatment or non-treatment options with Covered Persons irrespective of Amerigroup’s position on such treatment or non-treatment options or whether such treatment options are Covered Services.
(b) Acting within the lawful scope of such provider’s practice, advising or advocating on behalf of a Covered Person for such Covered Person’s health status, medical care, or treatment or non-treatment options, including any alternative treatments that might be self-administered by the Covered Person; or
(c) Advocating on behalf of a Covered Person within the utilization review or grievance processes established by Amerigroup or individual authorization process to obtain Medically Necessary Covered Services.
(a) Reduction of Payment. In the event that Amerigroup receives notice from Agency that Agency is due funds from a Subcontractor who has exhausted or waived the Agency administrative review process, if applicable, and that Agency instructs Amerigroup to collect such amount, on behalf of Agency, Amerigroup shall reduce payment to the Subcontractor for all claims submitted to Amerigroup by that Subcontractor by one hundred percent (100%), or such other amount as Agency may specify, until such time as the amount owed to Agency is recovered.
(b) Adjustment to Rates. In the event the Commissioner of Agency so directs Amerigroup, Amerigroup’s negotiated rates with Subcontractor shall be adjusted in order to reflect budgetary changes to the Program.
(a) Be in writing and must specify the activities and responsibilities delegated to the Subcontractor.
(b) Include provisions for revoking delegation or imposing other sanctions if the Subcontractor’s performance is inadequate.
(c) Include provisions to ensure that Amerigroup:(i) evaluates the prospective Subcontractor’s ability to perform the activities to be delegated; (ii) monitors the Subcontractor’s performance on an ongoing basis and subjects it to formal review according to a periodic schedule established by Agency (iii) is consistent with industry standards or State laws and regulations; (iv) and if deficiencies are identified or there are areas in need of improvement ensure that corrective action is taken.
(d) Include that all Subcontractors fulfill the requirements of 42 CFR 438.6 as appropriate.
(e) Comply with the requirements and provisions as set forth in Section 4.10 of the Program Contract.
(f) Include a requirement that there must be a designated project manager who is a member of the Subcontractor’s staff that is directly accessible by the Agency. This individual’s name and contact information must be provided to the Agency when the subcontract is executed.
(g) Contain a provision which requires Amerigroup and its Subcontractors to seek binding arbitration to resolve any dispute between Amerigroup and Subcontractor and to provide Agency with written notice of the dispute.
(h) Include a provision requiring Amerigroup and Subcontractor to maintain independence and to establish necessary policies and procedures to assist the Subcontractor in determining if any Subcontractors performing work under the subcontract have any impairment to their independence.
a. The dangers of drug abuse in the workplace;
b. Subcontractor’s policy of maintaining a drug-free workplace;
c. Any available drug counseling, rehabilitation, and employee assistance programs; and
d. The penalties that may be imposed upon employees for drug abuse violations;
a. Abide by the terms of the statement; and
b. Notify Amerigroup of any criminal drug statute conviction for a violation occurring in the workplace no later than five (5) calendar days after such conviction;
a. Taking appropriate personnel action against such an employee, up to and including termination; or
b. Requiring such employee to participate satisfactorily in a drug abuse assistance or rehabilitation program approved for such purposes by a federal, state, or local health, law enforcement, or other appropriate agency;
EXHIBIT E-7
Medicaid and Healthy Indiana Plan requirements for the State of Indiana
4. Termination of Attachment.
a. This Attachment shall automatically terminate upon the occurrence of any one of the following:
b. Except as otherwise provided herein, either party hereto may terminate this Attachment without cause upon ninety (90) calendar days prior written notice to the other party.
c. If either party fails to comply with or perform any term or condition of this Attachment, the other party shall notify the defaulting party of its default in writing, and the defaulting party shall have ninety (90) days to cure the default. If the default is not cured within said ninety (90) day period, this Attachment is automatically terminated, unless otherwise specified by the non-defaulting party
5. This Attachment shall be automatically amended to conform to applicable changes to State or Federal laws, rules, regulations or ordinances related to Medicaid Covered Individuals or the Indiana Medicaid program without the necessity of executing written amendments.
6. Nothing herein shall be construed to prohibit Subcontractor from contracting with other Medicaid managed care organizations.
7. Subcontractor shall be compensated pursuant to the amounts specified in the Agreement.
8. Subcontractor is not required to provide Services if Subcontractor objects to such service on moral or religious grounds.
9. Subcontractor certifies that neither it nor its principals nor any of its subcontractors are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from entering into this Attachment by any Federal agency or by any department, agency or political subdivision of the State. Subcontractor shall immediately notify Anthem if it or any of its principals becomes debarred or suspended, and Anthem shall, at the state's request, take all steps required by the state to terminate its contractual relationship with Subcontractor for work to be performed under this Attachment. For purposes of this Attachment, “principal” means an officer, director, owner, partner, key employee, or other person with primary
management or supervisory responsibilities, or a person who has a critical influence or substantive control over Subcontractor’s operations.
10. Subcontractor agrees to comply with the following:
a. Title VI of the Civil Rights Act of 1964 (Pub. L. 88-352), as amended, and all requirements imposed by or pursuant to the regulation of the Department of Health and Human Services (45 CFT Part 80), to the end that, in accordance with Title VI of that Act and the Regulation, no person in the United States shall on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity for which Subcontractor receives Federal assistance.
b. Section 504 of the Rehabilitation Act of 1973 (Pub. L. 93-112), as amended, and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 CFR Part 84), to the end that, in accordance with Section 504 of that Act and the Regulation, no otherwise qualified handicapped individual in the United States shall, solely by reason of his/her handicap, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity for which Subcontractor receives Federal assistance.
c. The Age Discrimination Act of 1975 (Pub. L 94-135), as amended, and all requirements imposed by or pursuant to the Regulation of the Department of Health and Human Services (45 CFR Part 91), to the end that, in accordance with the Act and the Regulation, no person in the United States shall, on the basis of age, be denied the benefits of, be excluded from participation in, or be subjected to discrimination under any program or activity for which Subcontractor receives Federal assistance.
d. The Americans with Disabilities Act of 1990 (Pub. L. 101-336), as amended, and all requirements imposed by or pursuant to the Regulation of the Department of Justice (28 CFR 35.101 et seq.), to the end that in accordance with the Act and Regulation, no person in the United States with a disability, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity for which Subcontractor receives Federal financial assistance.
e. Title IX of the Educational Amendments of 1972, as amended (30 U.S.C. sections 1681, 1783, and 1685-1686), and all requirements imposed by or pursuant to regulation, to the end that, in accordance with the Amendments, no person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity for which Subcontractor receives Federal financial assistance.
f. I.C. 22-9-1-10 and the Civil Rights Act of 1964, as amended, and any other applicable State or Federal law, regulations and executive orders prohibiting discrimination, in that Subcontractor shall not discriminate against any employee or applicant for employment in the performance of this Attachment. Subcontractor shall not discriminate with respect to the hire, tenure, terms, conditions or privileges of employment or any matter directly or indirectly related to employment, because of race, color, religion, sex, disability, national origin, ancestry or status as a veteran. Breach of this provision shall be considered default; and
g. All requirements applicable to Subcontractor under the Health Insurance Portability and Accountability Act of 1996.
EXHIBIT E-8
IOWA MEDICAID PARTICIPATION EXHIBIT AND
STATE-SPECIFIC REQUIREMENTS
This Iowa Medicaid Participation Exhibit and State Specific Requirements (the “Exhibit”) will supplement the Agreement (as defined herein) between Amerigroup Iowa, Inc. (“Contractor”) and Subcontractor (“Subcontractor”) effective upon approval and will run concurrently with the terms of the Agreement This Exhibit is limited to the terms and conditions governing the provision of services in the fulfillment of contractual responsibilities to the State of Iowa (“State”) in the provision of health care services. The provisions set forth in this Exhibit shall be deemed to be part of the Program Contract, and are intended to comply with legislative and Regulatory Requirements of the State. To the extent that such laws and regulations are applicable and/or are not otherwise preempted by federal law, the provisions set forth in this Exhibit shall apply. The provisions of this Exhibit apply with respect to individuals who are enrolled in the Iowa Medicaid Program (hereinafter collectively referred to as “Members”). Subcontractors shall be bound to the same contractual terms and conditions as the Contractor, all restrictions, obligations, and responsibilities of the Contractor under the Program Contract shall also apply to Subcontractors.
Type of Insurance | Limit | Amount |
General Liability (including contractual liability) written on occurrence basis | General Aggregate
Product/Completed Operations Aggregate
Personal Injury
Each Occurrence | $2 Million
$1 Million
$1 Million
$1 Million |
Automobile Liability (including any auto, hired autos, and non-owned autos)
| Combined Single Limit
| $1 Million |
Excess Liability, Umbrella Form | Each Occurrence
Aggregate | $1 Million
$1 Million |
Workers’ Compensation and Employer Liability | As required by Iowa law | As Required by Iowa law |
Property Damage
| Each Occurrence
Aggregate | $1 Million
$1 Million |
Professional Liability | Each Occurrence
Aggregate | $2 Million
$2 Million |
EXHIBIT E-9
KENTUCKY STATE-SPECIFIC REQUIREMENTS
This Exhibit is attached to the Agreement (the “Agreement”) between Anthem, Inc. (“Contractor”) on behalf its affiliate Anthem Kentucky Managed Care Plan, Inc. doing business as Anthem Blue Cross and Blue Shield Medicaid (hereinafter "Anthem") and “Center for the Study of Services” (“Subcontractor”) and is incorporated into the Agreement. This Exhibit is applicable to Subcontractor Services provided to or for the administration of the Kentucky Department for Medicaid Services (DMS). To the extent any provisions herein conflict with the provisions set forth in the Agreement, the provisions in this Exhibit shall control for those Subcontractor Services provided to Enrollees enrolled in the Cabinet for Health and Family Services (Cabinet), Department for Medicaid Services (Department) managed care program (“Medicaid”). The terms of the Medicaid Managed Care Contract between the Commonwealth of Kentucky on behalf of Department for Medicaid Services and Anthem (the “State Contract”) are hereby incorporated into this Exhibit. In the event the Department has not approved a Subcontract referenced herein prior to its scheduled effective date, Subcontractor agrees to execute said Subcontract contingent upon receiving the Department’s approval.
I. KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-
123: Anthem Subcontractor shall not request or require a provider to pursue any other course of action regarding the payment of health care claims outside of the provisions set forth in KRS 304.17A-700 to 304.17A-730 and KRS 205.593, 304.14-135, and 304.99-123.
J. Compliance with Regulatory Requirements. The parties hereto shall comply with all Regulatory Requirements applicable to the services performed under this Exhibit including, but not limited to, all applicable requirements of 42 C.F.R. Part 431, 42 C.F.R. Part 433, 42 C.F.R. Part 438, 42 C.F.R. Part 440, 42 C.F.R. Part 457, and 42 C.F.R. Part 494.
Services provided pursuant to this Agreement. This does not prohibit Subcontractor from collecting co-insurance, deductibles, or copayments as specifically provided in the evidence of coverage, or fees for uncovered Health Services delivered on a fee-for-service basis to persons referenced above, nor from any recourse against the health insuring corporation or its successor.
During the performance of this Contract, the Subcontractor agrees as follows:
employment without regard to their race, religion, color, national origin, sex, age or disability. Such action shall include, but not be limited to the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The Subcontractor agrees to post in conspicuous places, available to employees and applicants for employment, notices setting forth the provisions of this nondiscrimination clause or its nondiscriminatory practices.
this section received by the Subcontractor, together with any suggested resolution of the alleged violation proposed by the Subcontractor in response to the report, shall be reported to Finance within five (5) business days. Following consultation with the Contractor, Finance shall advise the Subcontractor of any further action it may deem appropriate in resolution of the violation. The Contractor will take such action with respect to any Subcontract or purchase order as the administering agency may direct as a means of enforcing such provisions including sanctions for noncompliance; provided, however, that in the event the Contractor becomes involved in, or is threatened with, litigation with a Subcontractor as a result of such direction by the agency, the Contractor may request the United States to enter or intervene into such litigation to protect the interests of the United States. Contractor shall comply with Title IX of the Education Amendments of 1972 (regarding education programs and activities), if applicable.
All records shall be maintained and available for review by authorized federal and state personnel during the entire term of this Contract and for a period of ten (10) years after termination of this Exhibit, except that when an audit has been conducted, or audit findings are unresolved. In such case records shall be kept for a period of ten (10) years in accordance with 907 KAR 1:672, or as amended or until all issues are finally resolved, whichever is later.
program. The UM program shall be evaluated annually, including an evaluation of clinical and service outcomes. The UM program evaluation along with any changes to the UM program as a result of the evaluation findings, will be reviewed and approved annually by the Medical Director, the Behavioral Health Director, or the Department.
The Department’s subcontract review shall assure that all Subcontracts:
The requirements of this section would be applicable to contracts with Subcontractors characterized as Risk Arrangements.
The requirements of this section shall not apply to Subcontracts for administrative services or other vendor contracts that do not provide Covered Services to Enrollees.
applicable. The Subcontractor shall not publish materials that are used for more than one Contractor without each Contractor being identified on the materials.
AA. Require participation in readiness reviews as requested by the Department, including submission of requested materials, participation in meetings, and onsite reviews.
BB. Include a requirement that Subcontractors notify the Contractor throughout the Contract Term of any new or existing litigation.
CC. Specify the remedies up to, and including, revocation of the Subcontract available to the Contractor if the Subcontractor does not fulfill its obligations. The Subcontractor shall also be subject to penalties as set forth in Appendix B “Remedies for Violation, Breach, or Non- Performance of Contract.”
EXHIBIT E-10
LOUISIANA STATE-SPECIFIC REQUIREMENTS COMMUNITY CARE HEALTH PLAN OF LOUISIANA, INC. D/B/A HEALTHY BLUE
DEFINITIONS
PROVISIONS
under the Contract. If MCO identifies deficiencies or areas for improvement Subcontractor shall take corrective action. In the event that Subcontractor's performance under the Subcontract is inadequate, MCO may revoke the Subcontract or may impose other sanctions.
undertaken pursuant to the Subcontract. The provision of such records shall be at no expense to LDH.
employees, and contractors, and do on-site reviews of all matters relating to service delivery as specified by the Contract. The rights of access in this provision are not limited to the required retention period but shall last as long as records are retained. The Subcontractor shall provide originals and/or copies (at no charge) of all records and information requested. Requests for information shall be compiled in the form and the language requested. The Subcontractor and the Subcontractor’s contracted providers shall comply, within a reasonable time, with any information, records or data request from any healthcare oversight agency, including the Louisiana Office of the Attorney General, Medicaid Fraud Control Unit (MFCU), related to any services provided under Louisiana’s Medical Assistance Programs. This requirement shall be inclusive of Contracts or Subcontracts with entities who manage or coordinate certain benefits for Medicaid beneficiaries on behalf of the MCO’s but does not directly provide the service to Medicaid beneficiaries. When requested by the MFCU the production of the information, records or data requested by the MFCU shall be done at no cost to the MFCU, and the MCO, Subcontractor or provider shall not require the MFCU to enter into any Contract, agreement, or memorandum of understanding to obtain the requested information, records or data. The MCO, Subcontractor and/or provider agrees that this Contract creates for the healthcare oversight agency an enforceable right for which the healthcare oversight agency can petition the court in the event of non-compliance with an information, records, or data request.
information to the MCO for reporting purposes required by LDH.
services to MCP Enrollees.
Enrollee who is his or her patient {1932(b)(3(D), 42 CFR §438.102(a)(1)(i),(ii),(iii) and (iv)}: a) for the Enrollee's health status, medical care, or treatment options, including any alternative treatment that may be self-administered; b) for any information the
Enrollee needs in order to decide among all relevant treatment options; c) for the risks, benefits, and consequences of treatment or non-treatment; and d) for the Enrollee's right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express references about future treatment decisions.
Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa. In addition, the Subcontractor will not hire any individual to perform any services under this Contract if that individual is required to have a work visa approved by the U.S. Department of Homeland Security and such individual has not met this requirement.
shall hold LDH and MCO harmless for actions taken as a result hereto.
EXHIBIT E-11
MARYLAND STATE-STATE SPECIFIC REQUIREMENTS AMERIGROUP MARYLAND, INC.
D/B/A AMERIGROUP COMMUNITY CARE
THIS ADDENDUM (“Addendum”) is made by and between AMERIGROUP Corporation and “Center for the Study of Services” (“Subcontractor”).
RECITALS
AMERIGROUP Corporation and Subcontractor are parties to that certain Agreement (the “Subcontract”), and wish to addend said Subcontract as provided herein.
AGREEMENT
IN CONSIDERATION of the mutual promises set forth herein, in the Subcontract, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:
This Addendum is limited to the terms and conditions governing the provision of services to or on behalf of AMERIGROUP Maryland, Inc. d/b/a AMERIGROUP Community Care in the fulfillment of AMERIGROUP Maryland, Inc. d/b/a AMERIGROUP Community Care’s contractual responsibilities to the Maryland Department of Health (“Department”) regarding all activities under the Managed Care Organization HealthChoice Provider Agreement (“Agreement”) between the Department and AMERIGROUP Maryland, Inc. d/b/a AMERIGROUP Community Care. This Addendum will supplement the Subcontract between AMERIGROUP Corporation and Subcontractor and will run concurrently with the terms of the Agreement.
EXHIBIT E-12
MINNESOTA STATE-SPECIFIC REQUIREMENTS MEDICARE AND MEDICAID ADDENDUM
For purposes of this Addendum, “Governmental Authority” means any, national, state, provincial, municipal, local, territorial or other governmental department, regulatory authority, or judicial or administrative body.
criminal offense or been the subject of a civil judgment for fraudulent activities related to that person’s/entity’s involvement in any federal health care program. Vendor shall not continue to pay for any items or services furnished, ordered or prescribed by excluded individuals or entities pursuant to 42 C.F.R. § 1001.1901 once Vendor becomes aware of such exclusion.
Vendor must check appropriate databases, including the Department of Health and Human Services Office of Inspector General (OIG) List of Excluded Individuals and Entities (available at https://oig.hhs.gov/exclusions.html) and the General Services Administration’s (GSA’s) Excluded Parties List System (available at http://www.sam.gov/), or such other/additional site(s) as may be designated from time to time by the OIG, GSA, CMS or other Governmental Authority, to determine whether any Affiliated Party has been excluded from participation in the Medicare program or any other federal health care program. These databases must be checked during the Term not less than monthly, provided that with respect to all Affiliated Parties, Vendor shall also check appropriate databases prior to when such Affiliated Parties commence their employment or other relationship (whether contractual or otherwise) with, or directorship or ownership of, Vendor. Vendor shall notify Blue Cross immediately, and in any event within no more than five (5) calendar days, in writing (i) if Vendor becomes excluded from the Medicare program or any other federal health care program, and (ii) upon becoming aware that any Affiliated Party becomes excluded from the Medicare program or any other federal health care program. Vendor agrees that it is subject to 2 C.F.R. Parts 180 and 376, and shall require Medicare subcontractors to comply with the requirements of 2 C.F.R. Parts 180 and 376. 2 C.F.R. § 376.332. Vendor agrees that it is subject to 2 C.F.R. Part 376 and shall require its Affiliated Parties to agree that they are subject to 2 C.F.R. Part 376. 42 C.F.R. §§ 422.752(a)(8), 423.752(a)(6).
Vendor shall maintain documentation sufficient to demonstrate its adherence to the requirements set forth in this Section 5(c) and shall, upon Blue Cross’s request, annually provide to Blue Cross a written, signed certification certifying as to Vendor’s compliance with same.
Vendor shall maintain such health and enrollment information in an accurate and timely manner and ensure timely access to such records and information by enrollees. 42 C.F.R
§§ 422.118, 422.504(13), 423.136, 423.505(b)(14).
Vendor shall maintain timely, accurate and complete records and books of account relating to Vendor’s performance under the Agreement. To the fullest extent applicable, Vendor recordkeeping shall adhere to generally accepted accounting principles, consistently applied. Vendor shall maintain these records in accordance with all applicable laws and at Vendor’s principal place of business. Vendor shall further comply with the retention requirements set forth below in Sections 10 and 11.
§ 422.516(a)(4).
Blue Cross and Vendor may agree in writing to specific forms that accomplish these reporting requirements. 42 C.F.R. §§ 422.504(i)(4)(i), 422.516, 423.505(i)(4)(i), 423.514.
submitted by Vendor on Blue Cross’s behalf, for the purpose of obtaining federal funds. 42 C.F.R. §§ 422.504(l)(3), 423.505(k)(3). To the extent that Vendor has access to the CMS or DHS information systems, or data obtained from such systems, for purposes of providing Services in connection with Blue Cross’ Medicare and Medicaid product offerings, Vendor’s use of or access to such data in connection with the Services shall be limited to the same.
42 C.F.R. §§ 422.504(i)(4)(iii), 423.505(i)(4)(iii). Vendor further acknowledges and agrees that Blue Cross is required to periodically monitor and audit Vendor to ensure that there is documented proof that the requirements described in this Addendum are being followed and Vendor agrees to cooperate and comply with such audits and monitoring activities.
(10) years from the expiration or termination of the Agreement or completion of final audit, whichever is later, unless otherwise required by applicable law; provided in all instances following the term of the Agreement, such right shall be limited to instances in which such audit is the result of a written notice from CMS, DHS, HHS, the Comptroller General or their designees. 42 C.F.R. §§ 422.504(e), 422.504(i)(2), 423.505(e), 423.505(i)(2).
(c). Vendor shall maintain records of the training of its staff and shall require the same of its authorized subcontractors conducted pursuant to this Section 11 in accordance with the requirements of Section 10(a).
(d) Vendor will communicate to employees and Vendor’s Delegate who are mandated reporters their duty to report the suspected maltreatment of a vulnerable adult or child as required under Minnesota Statutes, §§ 626.557 or 626.556. Vendor and Vendor’s Delegate must inform employees and providers that web-based training is available at no cost to all mandated reporters: http://registrations.dhs.state.mn.us/WebManRpt/ for adults and http://www.dhs.state.mn.us/id_000152 for children.
which Vendor has a compliance obligation under this Addendum. 42 C.F.R.§§ 422.504(i)(4)(v), 423.505(i)(4)(iv).
(30) days for drug claims submitted otherwise. 42 C.F.R. §§ 423.505(i)(3)(vi), 423.520.
§§ 423.505(b)(21), 423.505(i)(3)(viii)(A) and (B).
Agreement, Vendor shall notify Blue Cross within a defined period of time (to be mutually agreed upon by the Parties, but sufficient to allow Blue Cross to timely obtain all necessary Regulatory Approvals and/or comply with all applicable CMS or DHS filing or attestation requirements) in advance of offshoring any such function, activity or service related to the Agreement and provide Blue Cross with all information, other documentation, and reasonable cooperation necessary for Blue Cross to obtain all necessary Regulatory Approvals and/or submit applicable Regulatory Authority filing or attestation requirements, in each case, for such offshoring, which may include, without limitation, a description of the following: (i) PHI or electronic PHI that Vendor will provide to such person or entity; (ii) why providing PHI or electronic PHI is necessary to accomplish Vendor’s objectives; and
(iii) alternatives considered to avoid providing PHI or electronic PHI to such person or entity, and why each alternative was rejected. Vendor maintains a process to evaluate the use of offshore resources and will use best efforts (i.e., efforts commensurate with industry best practices) to inform Blue Cross of any evaluation related to or impacting Services or Professional Services.
and the associated auditing and monitoring Vendor performs and has performed. Vendor will complete such attestations and certifications as CMS, DHS, HHS, the Comptroller General or their designees and Blue Cross, relating to any submissions, attestations, or certifications that Blue Cross makes to CMS, DHS, HHS, the Comptroller General or their designees, may require certifying as to Vendor’s compliance with the requirements of this Section 14.
EXHIBIT E-13
STATE OF MISSOURI
MEDICAID STATE-SPECIFIC REQUIREMENTS
This Missouri Regulatory Exhibit (the “Exhibit”) will supplement the Agreement (the “Agreement”) between Missouri Care, Inc. (“Health Plan”) and Vendor (“Vendor”) effective upon approval, and will run concurrently with the terms of the Agreement. This Exhibit is limited to the terms and conditions governing the provision of services in the fulfillment of contractual responsibilities to the State of Missouri (“State”) in the provision of health care services. The provisions set forth in this Exhibit shall be deemed to be part of the Program Contract, and are intended to comply with legislative and regulatory requirements of the State. To the extent that such laws and regulations are applicable and/or are not otherwise pre-empted by federal law, the provisions set forth in this Exhibit shall apply. The provisions of this Exhibit apply with respect to individuals who are enrolled in a Medicaid Program (hereinafter collectively referred to as “Medicaid Members”).
For purposes of this Exhibit, the following terms shall have the meanings set forth below with respect to services furnished under the Missouri Medicaid Program. Any capitalized terms in this Exhibit not otherwise defined shall have the meaning ascribed in the Program Contract.
Missouri State-Specific Requirements
Page 99 of 338
(ii) owns five (5%) or more of any mortgage, deed of trust, note, or other obligation secured by the Vendor if that interest equals at least five (5%) of the value of the Vendor’s assets; (iii) is an officer or director of the Vendor organized as a corporation; or (iv) is a partner of the Vendor organized as a partnership upon execution of the Agreement and within thirty five (35) calendar days of any change in ownership of the organization.
thirty-five (35) calendar days of any change in ownership of the provider; and
(iv) at any time upon request by the Health Plan or Agency for any or all of the information described herein.
that may arise out of or are related to Vendor's performance under the Program Contract, providing such bodily injury or property damage is due to the negligence of the Vendor, its employees, agents, or subcontractors.
(viii) participating in three-way calls to the Missouri Medicaid Program enrollment helpline; (ix) suggesting a Medicaid Member transfer to another health plan; or (x) any other activities in which Provider is engaged in activities to enroll a Medicaid Member in a particular health plan or in any way assisting a Medicaid Member to enroll in a health plan.
prior to a Medicaid Member's enrollment with the Health Plan, even if the date of service fell within an established period of retroactive eligibility.
years from the end date of this Agreement or the last audit, whichever is later) of the Vendor’s or delegate’s premises, physical facilities, equipment, books, records, contracts, computers, or other electronic systems relating to the its activities under this Agreement, and to the Health Plan and the potential and enrolled Medicaid Members. Such audit, evaluations, or inspections may pertain to any aspect of services and activities performed, or determination of amounts payable under the Program Contract.
(i) In the case of capitated arrangements with providers, Vendor shall establish reasonable reporting of encounters to the Health Plan in sufficient detail to meet the Health Plan’s encounter data reporting requirements; (ii) in the case of services provided by out-of-network providers, Health Plan and Vendor shall comply with State law regarding timely filing requirements; and (iii) in the case of timely filing requirement, the first claim processed whether paid or denied should meet these guidelines.
EXHIBIT E-14
NEBRASKA STATE-SPECIFIC REQUIREMENTS
This Exhibit is attached to the Agreement (the “Agreement”) between Anthem, Inc. (“Contractor”) on behalf its affiliate Community Care Health Plan of Nebraska, Inc. d/b/a Healthy Blue (hereinafter "Community Care") and “Center for the Study of Services” (“Subcontractor”) and is incorporated into the Agreement. This Exhibit is applicable to Vendor Services provided to or for the administration of the State of Nebraska, Department of Health and Human Services, Division of Medicaid and Long-Term Care (the “State”). To the extent any provisions herein conflict with the provisions set forth in the Agreement, the provisions in this Exhibit shall control for those Subcontractor Services provided to Members enrolled in the State’s managed care program (“Medicaid”). The terms of the Medicaid Managed Care Physical Health, Behavioral Health, and Pharmacy Services for the State of Nebraska Contract between the State and Community Care (the “State Contract”) are hereby incorporated into this Exhibit. In the event the State has not approved a Subcontract referenced herein prior to its scheduled effective date, Subcontractor agrees to execute said Subcontract contingent upon receiving the State’s approval.
During the performance of this Contract, the Subcontractor agrees as follows:
Subcontractor’s commitments under this section, and shall post copies of the notice in conspicuous places available to employees and applicants for employment. The Subcontractor will take such action with respect to any Subcontract or purchase order as the State may direct as a means of enforcing such provisions, including sanctions for noncompliance.
entitled to the remedies accorded to third party beneficiaries under law. This Exhibit does not, nor is it intended to, create any rights, benefits or interest to any member, provider, provider network, subcontractor, delegated subcontractor, supplier, corporation, partnership or other organization of any kind.
All records shall be maintained and available for review by authorized federal and state personnel during the entire term of this Contract and for a period of ten (10) years after termination of this Exhibit, except that when an audit has been conducted, or audit findings are unresolved. In such case records shall be kept for a period of ten (10) years or until all issues are finally resolved, whichever is later.
shall be provided at no expense to the State, or any duly authorized State or federal agency.
455.100 through 455.106 (regarding disclosure by subcontractors of ownership and
control information and disclosure of information on a subcontractor’s owners' and other persons' conviction of criminal offenses against Medicare, Medicaid, or Title XX services program) and will agree to provide required disclosures at the time of initial contract, upon contract renewal, and/or upon request by Community Care. The Subcontractor further agrees to notify Community Care within 14 days of any changes to the required disclosures except that the Subcontractor shall notify Community Care immediately after it receives notice of any such convictions, deferred adjudications and all types of pretrial diversion programs as set forth in 42 CFR 455.106.
(b) What data elements were involved and the extent of the data involved in the Breach; (c) A description of the unauthorized persons known or reasonably believed to have improperly used or disclosed PHI or confidential data; (d) A description of where the PHI or confidential data is believed to have been improperly transmitted, sent, or utilized; (e) A description of the probable causes of the improper use or disclosure; and (f) Whether any federal or state laws requiring individual notifications of Breaches are triggered.
EXHIBIT E-15
NEVADA STATE-SPECIFIC REQUIREMENTS COMMUNITY CARE HEALTH PLAN OF NEVADA, INC.
D/B/A ANTHEM BLUE CROSS AND BLUE SHIELD HEALTHCARE SOLUTIONS
This Addendum will supplement the Agreement between Community Care Health Plan of Nevada, Inc. d/b/a Anthem Blue Cross and Blue Shield Healthcare Solutions (“Plan”) and Subcontractor effective upon approval (“Agreement”) and will run concurrently with the terms of the Agreement. This Addendum is limited to the terms and conditions governing the provision of services to or on behalf of Plan in the fulfillment of Plan’s contractual responsibilities to the Nevada Division of Health Care Financing and Policy (“DHCFP”) regarding all activities under the Contract as amended between the DHCFP and Plan.
To the extent any provision contained in this Addendum conflicts with the terms and conditions of the Agreement, the provision contained in this Addendum shall control.
For the purposes of this Addendum:
casualty insurance and such other kinds of insurance in such amounts, with such companies, and on such terms and conditions as the parties determine appropriate.
rule, or regulation, for periods in excess of ten (10) years or more when an audit is scheduled or in progress or in the event of any initiated or on-going litigation or appeal. The right to inspect, evaluate, and audit shall also extend through ten (10) years from the final date of the contract period or completion of audit, whichever is later unless: (i) CMS determines there is a special need to retain a particular record or group of records for a longer period and notifies the Subcontractor at least thirty (30) days before the normal disposition date; (ii) There has been a termination, dispute, or fraud or similar fault by the Subcontractor, in which case the retention may be extended to ten (10) years from the date of any resulting final resolution of the termination, dispute, or fraud or similar fault; or (iii) CMS determines that there is a reasonable possibility of fraud, in which case it may inspect, evaluate, and audit the Subcontractor at any time.
(a) affiliates of the Subcontractor and (b) the “Existing Subcontractors” defined below. If such prior written approval is required, such prior written approval shall not be unreasonably withheld or delayed. No subcontractor utilized by Subcontractor for services to ANTHEM or Plan shall relieve Subcontractor of its legal responsibility to ANTHEM and Plan. For purposes of the Agreement and this Addendum, an “affiliate” shall be a company, which controls, is controlled by, or is under common control with Subcontractor. For the purpose of this Section, “control” shall mean majority ownership.
timeframe as required and ANTHEM and/or Plan receives a financial penalty directly related to Subcontractor’s failure to provide ownership information, Subcontractor shall be liable to ANTHEM and/or Plan for the assessed penalty.
42 USC 1320a-7(b)(8) and the regulations implementing Executive Order 12549, Debarment and Suspension, 28 CFR Part 67, Section 67.510, published as Part VII of the May 26, 1988 Federal Register (pages 19160-19211). This paragraph shall be included in any subcontracts entered into by Subcontractor for services or work performed under the Agreement and/or this Addendum.
shall be included in any subcontracts entered into by Subcontractor for services or work performed under the Agreement and/or this Addendum.
that Subcontractor shall not provide any payments for items or services provided under the Agreement or this Addendum to any financial institution, entity or person located outside the United States of America.
Attachment I
Subcontractor shall be obligated to the following items as applicable based upon the services provided or work performed by Subcontractor.
629.061. Subcontractor agrees to retain medical records in accordance with all provisions listed in NRS 629.051, NRS 629.061, NRS 52.260, NRS 52.325, NRS 422.570 and 42 CFR
431.17 and any other applicable federal or state law.
authorized by the scope of their license to prescribe drugs, with the exception of all participating dentists;
notify DHCFP within 10 calendar days. If Subcontractor decredentials, terminates, or disenrolls a provider, the Subcontractor must inform Plan and/ or ANTHEM, within 5 calendar days. Plan and/or ANTHEM shall then notify DHCFP within 10 calendar days. If the decredentialing, termination or disenrollment of a provider is due to suspected criminal actions, or disciplinary actions relate to fraud or abuse DHCFP will notify HHS-OIG.
(15) business days after receipt or issuance of the termination notice. This notice shall be provided to each Member who received his/her primary care from, or was seen on a regular basis by, the terminated provider.
EXHIBIT E-16
NEW JERSEY STATE-SPECIFIC REQUIREMENTS
AMERIGROUP NEW JERSEY, INC.
DBA AMERIGROUP COMMUNITY CARE
(Verbatim Language Provisions Applicable to New Jersey Covered Persons)
This Exhibit is attached to and incorporated into the Agreement and is applicable solely to Vendor services provided to or for the administration to Medicaid members in New Jersey. The provisions set are intended to comply with legislative and regulatory requirements of the State of New Jersey. This Exhibit is limited to the terms and conditions governing the provision of services to or on behalf of AMERIGROUP New Jersey, Inc. (“Amerigroup”)in the fulfillment of AMERIGROUP New Jersey, Inc.’s contractual responsibilities to the Division of Medical Assistance and Health Services (“DMAHS”) regarding all activities under the Contract between the State of New Jersey (the “State”), Division of Medical Assistance and Health Services and AMERIGROUP New Jersey, Inc., as amended (“Contract”). This Exhibit will run concurrently with the terms of the Contract unless otherwise terminated sooner.
To the extent any provision contained in this Exhibit conflicts with the terms and conditions of the agreement, the provision contained in this Exhibit shall control.
Vendor agrees to serve Enrollees in New Jersey’s managed care program and, in doing so, to comply with all of the preceding and following provisions:
Required Provisions. The parties acknowledge and agree the provisions set forth below are provisions which include Verbatim Language, as defined below, which is required to be included in any contract by and between AMERIGROUP and AMERIGROUP’s vendors, and in all contracts, if any, between AMERIGROUP’s vendors and a person or entity with which said vendors subcontract for the provision of Covered Services (“Verbatim Language”).
Definitions.
For the purposes of this Exhibit the following terms have the meaning set forth below:
Any capitalized terms used in this section not otherwise defined shall have the meaning ascribed in the Government Contract.
Controlling Language. To the extent any provision contained within this Exhibit conflicts with any other provision set forth in the Subcontractor Contract, or any attachments, addenda, exhibits or schedules hereto, the provisions set forth in this Exhibit shall control for purposes of services attributable to services provided to or for the administration to Medicaid members in New Jersey.
Modifications or Amendments to the Verbatim Language. The parties acknowledge and agree that any and all modifications or amendments to the Verbatim Language from time to time made by the State of New Jersey or any of its applicable agencies shall be deemed included in this Exhibit and each of the parties shall be bound thereby as if such modifications or amendments are contained herein.
The Verbatim Language. The Subcontractor agrees to serve Enrollees in New Jersey’s managed care program and, in doing so, to comply with all the following provisions:
A. SUBJECTION OF SUBCONTRACTOR CONTRACT
This Subcontractor Contract/Subcontract shall be subject to the applicable material terms and conditions of the contract between the Contractor and the State and shall also be governed by and construed in accordance with all laws, regulations and contractual obligations incumbent upon the Contractor.
If applicable:
MLTSS Any Willing Provider and Any Willing Plan. Any New Jersey-based nursing facility (NF), special care nursing facility (SCNF), assisted living provider (AL), community residential services (CRS) provider that serves residents with traumatic brain injury, or long term care pharmacy that applies to become a network provider and complies with the Contractor’s provider network requirements shall be included in the Contractor’s provider network to serve MLTSS Members. In addition, if the Contractor wishes to have any New Jersey-based nursing facility (NF) special care nursing facility (SCNF), assisted living provider (AL), community residential services provider (CRS) join its network, those providers will be instructed to complete the application form. This is known as Any Willing Plan. The Contractor must accept all, SCNF, ALs, CRSs that serve residents with traumatic brain injury, and long term care pharmacies which are Medicaid Providers, and network participation of these provider types cannot be denied based on the application of a subjective standard.
The AWQP initiative quality measures were utilized to provide rate enhancements and the program was replaced by the Nursing Facility Quality Incentive Payment Program (NF QIPP).
The NF QIPP leverages quality outcome performance rate add-ons to state set Medicaid NF rate payments and is dependent on budget appropriations. The NF QIPP focuses on long-stay Medicaid residents, includes SCNFs, and excludes low volume Medicaid facilities with low Medicaid member census.
The NF QIPP currently uses six quality measures that includes five Minimum Data Set (MDS) measures that are collected by CMS under its Medicare Nursing Home Compare program and one resident and family satisfaction survey measure collected by NJ. The CoreQ Long Stay Satisfaction Survey is the tool utilized to determine a resident and family overall satisfaction score. These five core MDS measures are a part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes collected by CMS. DHS utilizes four standard quarters that are both finalized (no further revisions by CMS) and publicly available.
B. COMPLIANCE WITH FEDERAL AND STATE LAWS AND REGULATIONS
The Subcontractor agrees that it shall carry out the obligations as herein provided in a manner prescribed under applicable federal and State laws, regulations, codes, and guidelines including New Jersey licensing board regulations, DMAHS, NJ KidCare, and NJ FamilyCare State Plans, and in accordance with procedures and requirements as may from time to time be promulgated by the United Department of Health and Human Services.
1. The Subcontractor shall submit claims for medical services within 180 calendar days from the date of service.
2. The Subcontractor shall submit corrected claims for medical services within 365 days from the date of service.
3. The Subcontractor shall submit Coordination of Benefits (COB) claims within 60 days from the date of primary insurer’s Explanation of Benefits (EOB) or 180 days from the dates of service, whichever is later.
4. Electronic Visit Verification (EVV)
C. APPROVAL OF SUBCONTRACTOR CONTRACTS/SUBCONTRACTS AND AMENDMENTS
The Subcontractor understands that the State reserves the right in its sole discretion to review and approve or disapprove this Contract/Subcontract and any amendments thereto.
If applicable:
1. The Contractor and AWP provider shall only amend this Provider Contract unilaterally for statutory and regulatory changes, and upon mutual consent of the parties with State approval.
D. EFFECTIVE DATE
This Subcontractor Contract/Subcontract shall be effective only when the Contractor’s Agreement with the State takes effect.
E. NON-RENEWAL/TERMINATION OF SUBCONTRACTOR CONTRACT/ SUBCONTRACT
The Subcontractor understands that the Contractor shall notify DMAHS at least 30 days prior to the effective date of the suspension, termination, or voluntary withdrawal of the Subcontractor from participation in the Contractor’s network. If the termination was “for cause,” as related to fraud, waste and abuse, the Contractor's notice to DMAHS shall include the reasons for the termination. Subcontractor resource consumption patterns shall not constitute “cause” unless the Contractor can demonstrate it has in place a risk adjustment system that takes into account Enrollee health-related differences when comparing across Subcontractors.
F. ENROLLEE-PROVIDER COMMUNICATIONS
G. RESTRICTION ON TERMINATION OF SUBCONTRACTOR CONTRACT/
SUBCONTRACT BY CONTRACTOR
Termination of AWP providers is limited to State ordered termination as indicated Section H below. The Contractor shall not terminate this Subcontractor’s contract or Subcontract for either of the following reasons:
H. TERMINATION OF SUBCONTRACTOR CONTRACT AND SUBCONTRACTS – STATE
This Subcontractor understands and agrees that the State may order the termination of this Subcontractor Contract/Subcontracts if it is determined that the Subcontractor:
I. NON-DISCRIMINATION
The Subcontractor shall comply with the following requirements regarding nondiscrimination:
J. OBLIGATION TO PROVIDE SERVICES AFTER THE PERIOD OF THE CONTRACTOR’S INSOLVENCY AND TO HOLD ENROLLEES AND FORMER ENROLLEES HARMLESS
K. INSPECTION
The State, CMS, the Office of the Inspector General, the Comptroller General, and their designees may, at any time, inspect and audit any record or document of Amerigroup or its Subcontractors, and may, at any time inspect the premises, physical facilities, and equipment where Medicaid-related activities or work is conducted. The right to audit under this section exists for ten (10) years from the final date of the contract period or from the date of completion of any audit, whichever is later.
If the State, CMS, or the HHS Inspector General determines that there is a reasonable possibility of fraud or similar risk, the State, CMS, or the HHS Inspector General may inspect, evaluate, and audit the Subcontractor at any time. DMAHS, the MFD, or its designee, and the MFCU, shall have the right to inspect, evaluate, and audit all of the following documents in whatever form they are kept including but not limited to, all physical and computer or other electronic records and systems, originated or prepared pursuant to, or, related to the Subcontractor Contract / Subcontracts:
1. Financial records, including but not limited to tax returns, invoices, inventories, delivery receipts, Medicaid claims;
2. Medical records, including but not limited to medical charts, prescriptions, x-rays, treatment plans, medical administration records, records of the provision of activities of daily living, ambulance call reports;
3. Administrative documents, including but not limited to credentialing files, appointment books, prescription log books, correspondence of any kind with Contractor, DMAHS, CMS, any other
managed care contractor, Medicaid recipient, contracts with subcontractors, and contracts with billing service subcontractors; and
4. All records required to be kept to fully disclose the extent of services provided to Medicaid recipients, pursuant to NJAC 10:49-9.8(b) (1).
L. RECORD MAINTENANCE
The Subcontractor shall agree to maintain all of its books and records in accordance with the general standards applicable to such book or record keeping.
M. RECORD RETENTION AND SUBCONTRACTOR DOCUMENTATION REQUIREMENTS
Subcontractor Documentation Requirements - The Subcontractor shall, at a minimum, maintain such records as are necessary to fully disclose the nature and extent of services provided, in accordance with N.J.S.A. 30:4D-12(d) and N.J.A.C. 10:49-9.8. The Subcontractor shall also comply with the documentation requirements set forth in this Section M, as applicable. To the extent that the Contractor has imposed more stringent requirements than those imposed by law, regulation or this Section M, the more stringent requirements shall prevail. The provisions of N.J.S.A 30:4D-12(e) and N.J.A.C. 10:49-5.5(a)13. i. through iv. may apply to these documentation requirements.
Record Retention Requirements - Records must be retained for the later of ten (10) years from the date of service or after the final payment is made under the Subcontractor Contract/Subcontract and all pending matters are closed
If an audit, investigation, litigation, or other action involving the records is started before the end of the retention period, the records shall be retained until all issues arising out of the action are resolved or until the end of the retention period, whichever is later. Records shall be made accessible at a New Jersey site and on request to agencies of the State of New Jersey and the federal government. For Enrollees who are eligible through the Division of Child Protection and Permanency, records shall be kept in accordance with the provisions under N.J.S.A. 9:6-8.10a and 9:6-8:40 and consistent with need to protect the Enrollee's confidentiality.
If an Enrollee disenrolls from the Contractor, the Subcontractor shall release medical records of the Enrollee as may be directed by the Enrollee, authorized representatives of DMAHS and appropriate agencies of the State of New Jersey and of the federal government. Release of records shall be consistent with the provision of confidentiality expressed in Section 2.R., Confidentiality, and at no cost to the Enrollee.
Compliance with Specific Requirements - Subcontractors must comply with the following requirements:
a) Medical supplies and equipment require a legible, dated prescription or a dated Certificate of Medical Necessity (CMN) personally or electronically signed by the prescribing practitioner. Either document shall contain the following information:
i) The beneficiary's name, address, gender and Medicaid/NJ FamilyCare eligibility identification number;
ii) A detailed description of the specific supplies and/or equipment prescribed;
iii) The length of time the medical equipment items or supplies are required;
iv) A diagnosis and summary of the patient's physical condition to support the need for the item(s) prescribed; and
v) The prescriber's printed name, address and signature.
a) All orders for clinical laboratory services shall be in the form of an explicit order personally signed by the physician or other practitioner whose license permits them to request the services, or be in an alternative form of order specifically authorized in (b) (i) through (iii) below. All orders shall be patient specific, contain the specific clinical laboratory test(s) requested, seek only medically necessary tests, shall be on file with the billing laboratory, and shall be available for review by Medicaid/NJ FamilyCare representatives upon request.
b) If a signed order is not utilized, then clinical laboratory services shall be ordered in one of the following ways:
i) In the absence of a written order, the patient's chart or medical record may be used as the test requisition or authorization, but must be physically present at the laboratory at the time of testing and available to Federal or State representatives upon request;
ii) A test request also may be submitted to the laboratory electronically if the system used to generate and transmit the electronic order has adequate security and system safeguards to prevent and detect fraud and abuse and to protect patient confidentiality. The system shall be designed to prevent and detect unauthorized access and modification or manipulation of records, and shall include, at a minimum, electronic encryption; or
iii) Telephoned or other oral laboratory orders are also permissible, but shall be followed up with a written or electronic request within 30 days of the telephone or other oral request, which shall be maintained on file with the clinical laboratory. If the laboratory is unable to obtain the written or electronic request, it must maintain documentation of its efforts to obtain them.
c) Standing orders shall be:
i) Patient specific, and not blanket requests from the physician or licensed practitioner;
ii) Medically necessary and related to the diagnosis of the recipient; and
iii) Effective for no longer than a 12-month period from the date of the physician's/practitioner's order.
d) The laboratory must ensure that all orders described in (a) through (c) above contain the following information:
i) The name and address or other suitable identifiers of the authorized person requesting the test and, if appropriate, the individual responsible for using the test results, or the name and address of the laboratory submitting the specimen, including, as applicable, a contact person to enable the reporting of imminently life-threatening laboratory results or panic or alert values;
ii) The patient's name or unique patient identifier;
iii) The sex (if known) and date of birth of the patient;
iv) The specific test(s) to be performed;
v) The source of the specimen, when appropriate;
vi) The date and, if appropriate, time of specimen collection;
vii) For Pap smears, the patient's last menstrual period, and indication of whether the patient had a previous abnormal report, treatment or biopsy;
viii) For drug testing, the order shall indicate whether the test is for screening (presumptive) or confirmation (definitive) purposes and the specific drug classes to be tested as defined by the American Medical Association;
ix) Any additional information relevant and necessary for a specific test to ensure accurate and timely testing and reporting of results, including interpretation, if applicable.
e) All orders and results of the tests billed shall be on file with the billing laboratory performing the tests. The results of the tests, clinical and billing records shall be available for review by Medicaid/NJ FamilyCare representatives.
f) The Medicaid/NJ FamilyCare program shall have the right to inspect all records, files and documents of in-State and out-of-State service and reference clinical laboratories which provide laboratory tests and services for Medicaid/NJ FamilyCare beneficiaries.
g) All laboratory test orders shall be supported by documentation in the referring physician's/practitioner's medical records.
h) If the laboratory uploads, transcribes or enters test requisition or authorization information into a record system or a laboratory information system, the laboratory must ensure that the information is transcribed or entered accurately.
3) Services Provided by a Psychologist
a) Psychologists shall keep such individual records as may be necessary to disclose fully the kind and extent of services provided and shall make such information available when requested by the New Jersey Medicaid/NJ FamilyCare program or its agents. The recordkeeping shall document the services provided as they relate to the procedure code(s) used for reimbursement purposes (see N.J.A.C.10:67-3, Healthcare Common Procedure Coding System).
b) For the initial examination, the record shall include, as a minimum, the following:
i) Date(s) of service rendered;
ii) Signature of the psychologist;
iii) Chief complaint(s);
iv) Pertinent historical, social, emotional, and additional data;
v) Reports of evaluation procedures undertaken or ordered;
vi) Diagnosis; and
vii) The intended course of treatment and tentative prognosis.
c) For subsequent progress notes made for each Medicaid/ NJ FamilyCare patient contact, the following shall be included on the psychotherapeutic progress note:
i) Date(s) and duration of service (for example, hour, half-hour);
ii) Signature of the psychologist;
iii) Name(s) of modality used, such as individual, group, or family therapy;
iv) Notations of progress, impediments, or treatment complications; and
v) Other components, such as dates or information not included in (c)1 through 4 above, which may be important to the clinical description and prognosis.
vi) One or more of the following components shall be recorded to delineate the visit and establish its uniqueness. (Not all of the components need be included):
4) Mental Health Services Provided by an Independent Clinic
a) An intake evaluation shall be performed within 14 days of the first encounter or by the third clinic visit, whichever is later, for each beneficiary being considered for continued treatment. This evaluation shall consist of a written assessment that:
i) Evaluates the beneficiary's mental condition;
ii) Determines whether treatment in the program is appropriate, based on the beneficiary's diagnosis;
iii) Includes certification, in the form of a signed statement, by the evaluation team, that the program is appropriate to meet the beneficiary's treatment needs; and
iv) Is made part of the beneficiary's records.
v) The evaluation for the intake process shall include a physician or advance practice nurse (APN) and an individual experienced in the diagnosis and treatment of mental illness. Both criteria may be satisfied by the same individual, if appropriately qualified.
b) A written, individualized plan of care shall be developed for each beneficiary who receives continued treatment. The plan of care shall be designed to improve the beneficiary's condition to the point where continued participation in the program, beyond occasional maintenance visits, is no longer necessary. The plan of care shall be included in the beneficiary's records and shall consist of:
i) A written description of the treatment objectives including the treatment regimen and the specific medical/remedial services, therapies, and activities that shall be used to meet the objectives.
ii) A projected schedule for service delivery which includes the frequency and duration of each type of planned therapeutic session or encounter;
iii) The type of personnel that will be furnishing the services; and
iv) A projected schedule for completing reevaluations of the beneficiary's condition and updating the plan of care.
c) The mental health clinic shall develop and maintain legibly written documentation to support each medical/remedial therapy service, activity, or session for which billing is made.
i) This documentation, at a minimum, shall consist of:
d) Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the beneficiary's medical record at least once a week, as well as any other information important to the clinical picture, therapy, and prognosis.
e) The individual services under partial care shall be documented on a daily basis. More substantive documentation, including progress notes and any other information important to the clinical picture, are required at least once a week.
f) Periodic review of the beneficiary's plan of care shall take place at least every 90 days during the first year and every six months thereafter.
i) The periodic review shall determine:
ii) Periodic reviews shall be documented in detail in the beneficiary's records and made available upon request to the New Jersey Medicaid or NJ FamilyCare program or its agents.
5) APN Services:
a) The APN, in any and all settings, shall keep such legible individual written records and/or electronic medical records (EMR) as are necessary to fully disclose the kind and extent of service(s) provided, the procedure code being billed and the medical necessity for those services.
b) Documentation of services performed by the APN shall include, as a minimum:
i) The date of service;
ii) The name of the beneficiary;
iii) The beneficiary's chief complaint(s), reason for visit;
iv) Review of systems;
v) Physical examination;
vi) Diagnosis;
vii) A plan of care, including diagnostic testing and treatment(s);
viii) The signature of the APN rendering the service; and
ix) Other documentation appropriate to the procedure code being billed. (See N.J.A.C. 10:58A-4, HCPCS Codes.)
c) In order to receive reimbursement for an initial visit, the following documentation, at a minimum, shall be placed on the medical record by the APN, regardless of the setting where the examination was performed:
i) Chief complaint(s);
ii) A complete history of the present illness, with current medications and review of systems, including recordings of pertinent negative findings;
iii) Pertinent medical history;
iv) Pertinent family and social history;
v) A complete physical examination;
vi) Diagnosis; and
vii) Plan of care, including diagnostic testing and treatment.
d) In order to document the record for reimbursement purposes, the progress note for routine office visits or follow up care visits shall include the following:
i) In an office or residential health care facility:
ii) In a hospital or nursing facility setting:
e) To qualify as documentation that the service was rendered by the APN during an inpatient stay, the medical record shall contain the APN's notes indicating that the APN personally:
i) Reviewed the beneficiary's medical history with the beneficiary and/or his or her family, depending upon the medical situation;
ii) Performed a physical examination, as appropriate;
iii) Confirmed or revised the diagnosis; and
iv) Visited and examined the beneficiary on the days for which a claim for reimbursement is made.
f) The APN's involvement shall be clearly demonstrated in notes reflecting the APN's personal involvement with, or participation in, the service rendered.
g) For all EPSDT examinations for individuals under 21 years of age, the following shall be documented in the beneficiary's medical record and shall include:
i) A history (complete initial for new beneficiary, interval for established beneficiary) including past medical history, family history, social history, and systemic review.
ii) A developmental and nutritional assessment.
iii) A complete, unclothed, physical examination to also include the following:
iv) The assessment and administration of immunizations appropriate for age and need;
v) Provisions for further diagnosis, treatment and follow-up, by referral if necessary, of all correctable abnormalities uncovered or suspected;
vi) Mandatory referral to a dentist for children aged twelve months or older;
vii) The laboratory procedures performed or referred if medically necessary per Bright Futures guidelines.
viii) Health education and anticipatory guidance; and
ix) An offer of social service assistance; and, if requested, referral to a county welfare agency.
h) The record and documentation of a home visit or house call shall become part of the office progress notes and shall include, as appropriate, the following information:
i) The beneficiary's chief complaint(s), reason for visit;
ii) Pertinent medical, family and social history obtained;
iii) Pertinent physical findings;
iv) The procedures, if any performed, with results;
v) Lab, X-ray, ECG, etc., ordered with results; and
vi) Diagnosis(es) plus treatment plan status relative to present or pre-existing illness(es) plus pertinent recommendations and actions.
6) Physician Services
a) Physician Recordkeeping; general
i) All physicians shall keep such legible individual records as are necessary to fully disclose the kind and extent of services provided, as well as the medical necessity for those services.
ii) The minimum recordkeeping requirements for services performed in the office, home, residential health care facility, nursing facility (NF), and the hospital setting shall include a progress note in the clinical record for each visit, which supports the procedure code(s) claimed.
iii) The progress note shall be placed in the clinical record and retained in the appropriate setting for the service performed.
iv) Records of Residential Health Care Facility patients shall be maintained in the physician's office.
v) The required medical records including progress notes, shall be made available, upon their request, to the New Jersey Medicaid/NJ FamilyCare program or its agents.
b) Minimum documentation; initial visit; new patient
i) The following minimum documentation shall be entered on the medical record, regardless of the setting where the examination is performed, for the service claimed by use of the procedure codes for Initial visit—New patient:
c) Minimum documentation; established patient
i) The following minimum documentation shall be entered in the progress notes of the medical record for the service designated by the procedure codes for ESTABLISHED PATIENT:
(a) The purpose of the visit;
(b) The pertinent physical, family and social history obtained;
(c) A record of pertinent physical findings, including pertinent negative findings based upon (a) and (b) above;
(d) Procedures performed, if any, with results
(e) Laboratory, X-Ray, electrocardiogram (ECG), or any other diagnostic tests ordered, with the results of the tests; and
(f) Prognosis and diagnosis.
d) Minimum documentation; home visits and house calls
i) For HOME VISIT and HOUSE CALL codes, in addition to the components listed in N.J.A.C. 10:54-2.8, the office progress notes shall include treatment plan status relative to present or pre-existing illness(es), plus pertinent recommendations and actions.
e) Minimum documentation; hospital or nursing facility
i) In a hospital or nursing facility, documentation shall include:
f) Minimum documentation; hospital discharge medical summary
i) When an inpatient is discharged from the hospital to the care of another medical facility (such as a nursing facility or a community home care agency), a legible discharge and medical summary shall be prepared and signed by the attending physician.
ii) The summary should cover the pertinent findings of the history, physical examination, diagnostic and therapeutic modalities, consultations, plan of care or therapy, medications, recommendations for follow-up care and final diagnosis related to the patient's hospitalization. Recommendations should also be made for further medical care and should be forwarded to the institution or agency to which the patient has been referred or discharged.
g) Minimum documentation; mental health services
i) For each patient contact made by a physician for psychiatric therapy, written documentation shall be developed and maintained to support each medical or remedial therapy, service, activity, or session for which billing is made. The documentation, at a minimum, shall consist of the following:
ii) Clinical progress, complications and treatment which affect prognosis and/or progress shall be documented in the patient's medical record, as well as any other information important to the clinical picture, therapy, and prognosis. For mental health services that are not specifically included in the patient's treatment regime, a detailed explanation shall be submitted with the claim form, addressed to the Office of Managed Behavioral Services, Mail Code #25, PO Box 712, Trenton, New Jersey 08625-0712, indicating how these services relate to the treatment regime and objectives in the patient's plan of care. Similarly, a detailed explanation should accompany bills for medical and remedial therapy, session or encounter that departs from the Plan of Care in terms of need, scheduling, frequency or duration of services furnished (for example, unscheduled emergency services furnished during an acute psychotic episode) explaining why this departure from the established treatment regime is necessary in order to achieve the treatment objectives.
7) Pharmaceutical services
a)Pharmacies shall keep and maintain wholesaler, manufacturer, and distributor invoices and other purchase invoices and documents for prescription drugs and medical supplies for a minimum of ten (10) years. Purchase records must indicate price, drug name, dosage form, strength, NDC, lot number and quantity. Pharmacies shall also maintain adequate records to validate purchases from wholesalers including but not limited to canceled check information. Pharmacies must promptly comply with any requests to produce such documentation to DMAHS and/or MFD.
b) Invoices and documentation required by subsection (a) must substantiate that the prescription drugs or medical supplies dispensed were purchased from an authorized source regulated by the federal/state entities and National Association of Boards of Pharmacy - Verified Accredited Wholesaler Distributors (NABPVAWD). Pharmacies shall provide product tracing information (i.e. pedigree) to DMAHS and/or MFD upon request.
c) Pharmacies are required to have a product in stock at the pharmacy prior to submitting a claim for the product. All claims submissions shall contain the National Drug Code (NDC) of
the product dispensed. Only the NDC of the actual product dispensed shall be submitted on the claim. Use of a similar NDC of a product not dispensed is not permissible.
d)Pharmacies shall keep and maintain any compound recipe worksheets identifying ingredients used in a compounded prescription drug. Pharmacies must submit claims with all ingredients included in each compound and may only submit claims with the NDC associated with the actual ingredients filled/dispensed. Pharmacies must promptly comply with any requests to produce such electronic or paper documentation to the Medicaid/NJ FamilyCare program and/or its agents.
e) Pharmacies may transfer inventory to alleviate a temporary shortage, or for the sale, transfer, merger or consolidation of all or part of the business of a pharmacy from or with another pharmacy, whether accomplished as a purchase and sale of stock or business assets. The transfer or purchase of covered legend and nonlegend products or medical supplies from another licensed pharmacy must be verified and documented as originating from a NABP-VAWD and licensed drug wholesaler. All records involved in the transfer must be maintained and accessible for ten (10) years. These records shall be contemporaneous with the transfer and shall include the name of the prescription drug or medical supply, dosage form, strength, NDC, lot number, quantity and date transferred. Additionally, records must indicate the supplier or manufacturer’s name, address and registration number.
N. DATA REPORTING
The Subcontractor agrees to provide all necessary information to enable the Contractor to meet its reporting requirements, including specifically with respect to encounter reporting. The encounter data shall be in a form acceptable to the State.
a. Diagnosis Code
b. Procedure Code
c. Sex
d. Discharge Status Code
e. Date of Birth
f. Newborn Birth Weight
g. Admission Date
h. Discharge Date
i. Skilled level of Care (SNF) or Administrative Days and associated dates
j. Residential level of Care (denied days) and associated dates
a. In the event that the NJUR review results in an adverse determination, the Subcontractor shall adjust the claim pursuant to the adverse determination or appeal the decision utilizing the NJUR appeal process.
O. DISCLOSURE
P. LIMITATIONS ON COLLECTION OF COST-SHARING
The Subcontractor shall not impose cost-sharing charges of any kind upon Medicaid or NJ FamilyCare A, B and ABP Enrollees. Personal contributions to care for NJ FamilyCare C Enrollees and copayments for NJ FamilyCare D Enrollees shall be collected in accordance with the attached schedule.
Q. INDEMNIFICATION BY SUBCONTRACTOR
R. CONFIDENTIALITY
S. CLINICAL LABORATORY IMPROVEMENT
The Subcontractor shall ensure that all laboratory testing sites providing services under this Subcontract Contract/Subcontract have either a Clinical Laboratory Improvement Amendment (CLIA) certificate of waiver or a certificate of registration along with a CLIA identification number. Those laboratory service Subcontractors with a certificate of waiver shall provide only those tests permitted under the terms of their waiver. Laboratories with certificates of registration may perform a full range of laboratory tests.
T. FRAUD, WASTE, AND ABUSE
U. THIRD PARTY LIABILITY
V. ENROLLEE PROTECTIONS AGAINST LIABILITY FOR PAYMENT
W. OFF-SHORE
X. FURTHER DELEGATION OF ANY DELEGATED ACTIVITY IS NOT PERMISSIBLE.
ADDITITIONAL REGULATORY REQUIREMENTS
A. WRITTEN POLICIES REQUIRED WHEN ENTITY RECIEVES $5,000,000 OR MORE
1. Any Subcontractor/entity that receives or makes annual payments under the State plan of at least $5,000,000, as a condition of receiving such payments, shall:
EXHIBIT E-17
New York State-Specific Requirements (Empire)
This Exhibit is attached to and incorporated into the Agreement (as defined below) and is applicable solely to Vendor’s services as described in the Agreement provided to or for the administration of the Programs (as defined herein) in the State of New York. To the extent, any provisions herein conflict with the provisions set forth in the Agreement, the provisions in this Exhibit shall control for the Vendor’s services that are provided to individuals who are enrolled in the Programs (hereinafter collectively referred to as “Members”).
Subject to the New York State Department of Health (“SDOH”) approval, if such is required, HealthPlus HP, LLC, dba Empire BlueCross BlueShield HealthPlus (“Company”) may subcontract for administrative and management services including, but not limited to, quality assurance and utilization review activities and such other services as are set forth in the Program Contract. In addition, Company must oversee and evaluate Vendor’s ability to perform the delegated activities.
For the purposes of this Exhibit, the following definitions shall apply. Any capitalized terms in this Exhibit not otherwise defined shall have the meaning ascribed to them in the Program Contract.
Notwithstanding any provision to the contrary in the Agreement, or in any subcontract flowing out of the Agreement, or any subcontract flowing out of the Program Contract, Vendor agrees as follows:
a period of ten (10) years thereafter, except that the Vendor shall retain Member’s medical records that are in its possession for a period of ten (10) years after the date of service rendered to the Member, of cessation of Company’s operation, and in the case of a minor, for ten (10) years after the date of service or three (3) years after majority, whichever occurs later;
The affiliate relationship is described as follows:
Please refer to the Federal Debarment List located at: www.epls.arnet.gov for a listing of federally debarred and suspended individuals/entities.
U.S.C. §3729 et seq., State Finance Law § 187 et seq., Social Services Law § 145-b or other New York or Federal statutes, regulations or rules.
same or similar specialty as the health care professional under review. The hearing panel may consist of more than three persons, provided however, that the number of clinical peers on such panel shall constitute one-third or more of the total membership of the panel.
U.S.C. § 3729 et seq.; for contractors operating in New York City, the New York City Health Code; and all other applicable legal and regulatory requirements in effect at the time that the Agreement is signed and as adopted or amended during the term of the Agreement. The parties agree that the Agreement shall be interpreted according to the laws of the State of New York.
Other prohibited outreach activities include:
EXHIBIT E-18
New York State-Specific Requirements (Highmark)
This Exhibit is attached to and incorporated into the Agreement (as defined below) and is applicable solely to Vendor’s services as described in the Agreement provided to or for the administration of the Programs (as defined herein) in the State of New York. To the extent, any provisions herein conflict with the provisions set forth in the Agreement, the provisions in this Exhibit shall control for the Vendor’s services that are provided to individuals who are enrolled in the Programs (hereinafter collectively referred to as “Members”).
Amerigroup Partnership Plan, LLC (“APP”) and Amerigroup Corporation (“AC”) (collectively “Amerigroup”) are contracted with Highmark Western and Northeastern New York Inc. dba Highmark Blue Cross Blue Shield of Western New York (“Highmark”) to provide certain administrative and management services pursuant to a Management and Administrative Services Agreement in which services are provided in relation to the Program Contract between Highmark and the New York State Department of Health (“SDOH”). As Highmark and Amerigroup are jointly responsible for rights and responsibilities outlined in the Agreement, they are collectively referred to as “Company”. When referring to each individual entity, such shall be referred to as Amerigroup or Highmark as applicable.
Subject to SDOH approval, if such is required, Company may subcontract for administrative and management services including, but not limited to, quality assurance and utilization review activities and such other services as are set forth in the Program Contract. In addition, Company must oversee and evaluate Vendor’s ability to perform the delegated activities.
For the purposes of this Exhibit, the following definitions shall apply. Any capitalized terms in this Exhibit not otherwise defined shall have the meaning ascribed to them in the Program Contract.
Notwithstanding any provision to the contrary in the Agreement, or in any subcontract flowing out of the Agreement, or any subcontract flowing out of the Program Contract, Vendor agrees as follows:
time, its premises, physical facilities, and equipment where Medicaid-related activities or work is conducted;
The affiliate relationship is described as follows:
Please refer to the Federal Debarment List located at: www.epls.arnet.gov for a listing of federally debarred and suspended individuals/entities.
SDOH, DHHS, Office of the Medicaid Inspector General (“OMIG”), Office of the State Comptroller (“OSC”) or the New York State Office of the Attorney General.
U.S.C. §3729 et seq., State Finance Law § 187 et seq., Social Services Law § 145-b or other New York or Federal statutes, regulations or rules.
reasons for termination and the opportunity for a hearing or review concerning such termination.
U.S.C. § 3729 et seq.; for contractors operating in New York City, the New York City Health Code; and all other applicable legal and regulatory requirements in effect at the time that the Agreement is signed and as adopted or amended during the term of the Agreement. The parties agree that the Agreement shall be interpreted according to the laws of the State of New York.
Other prohibited outreach activities include:
EXHIBIT E-19
NORTH CAROLINA MEDICAID PROGRAM PARTICIPATION EXHIBIT AND SPECIFIC REQUIREMENTS
This North Carolina Medicaid Program Participation Exhibit and Specific Requirements (the “Regulatory Exhibit”) will supplement the Agreement (the “Agreement”) between Amerigroup Partnership Plan, LLC (“Amerigroup”) and Vendor (“Vendor”) and will run concurrently with the terms of the Agreement. Amerigroup Partnership Plan, LLC (“Amerigroup”) is contracted with Blue Cross Blue Shield North Carolina (“Blue Cross NC”) to provide certain administrative and operational services pursuant to a Marketing and Administrative Services Agreement in which services are provided in relation to the Program Contract between Blue Cross NC and DHHS. As Blue Cross NC and Amerigroup are jointly responsible for rights and responsibilities outlined in the Agreement, they are collectively referred to as “Company” such reference may apply jointly or separately.
Vendor agrees the provisions set forth in this Regulatory Exhibit shall be deemed to be part of the Agreement as applicable to services rendered by Vendor and are intended to comply with legislative and regulatory requirements of the Agency. To the extent that such laws and regulations are applicable and/or are not otherwise preempted by federal law, the provisions set forth in this Regulatory Exhibit shall apply. The provisions of this Regulatory Exhibit apply with respect to individuals who are enrolled in the Blue Cross North Carolina Medicaid Program (hereinafter collectively referred to as “Members”). These provisions shall also be incorporated into any subcontracts whether by reference or as expressly set forth. Failure of Vendor to incorporate these provisions shall not relieve Vendor or its subcontractors from compliance with applicable provisions.
operation of a health benefit plan, or the performance required by either party under the Agreement and this Regulatory Exhibit. The omission from the Agreement or this Regulatory Exhibit of an express reference to a Regulatory Requirement applicable to either party in connection with their duties and responsibilities shall in no way limit such party's obligation to comply with such Regulatory Requirement.
performance under the Agreement as confidential information and shall not use such information except as provided under the Agreement and the Program Contract. Any use, sale, or offer of confidential information except as contemplated under the Agreement or the Program Contract or approved in writing by the Agency shall be a violation of the Agreement and Program Contract. Any such violation will be considered a material breach of the Agreement. Vendor specifically warrants that it, its officers, directors, principals, employees, any subcontractors, and approved third-party contractors shall hold all information received during performance of the Agreement in the strictest confidence and shall not disclose the same to any third party except as contemplated under the Agreement or approved in writing by Company.
(12) hours after the incident is first discovered. If a Social Security number has been compromised, the incident must be reported to Company within thirty (30) minutes of discovery of the incident.
subcontractors, and in all contracts, if any, between Company’s subcontractors and a person or entity with which said subcontractor contracts with for the provision of health care services (“Government Language”).
equitably. The Vendor agrees not to discriminate against Members on the basis of race, color, national origin, age, sex, gender, or disability.
U.S. Department of Justice, or any of the foregoing entities' contractors or agents, to enforce federal requirements for the submission of documentation in response to an audit or investigation.
information on persons convicted of crimes related to any federal health care programs. The Vendor agrees to notify, in writing, the Company and the NC Department of Health and Human Services of any criminal conviction within twenty (20) days of the date of the conviction.
EXHIBIT E-20
OHIO REGULATORY EXHIBIT
This Ohio Regulatory Exhibit (the “Exhibit”) will supplement the Agreement (the “Agreement”) between Community Insurance Company d/b/a Anthem Blue Cross and Blue Shield (“Anthem”) and Subcontractor (“Subcontractor”) effective upon approval, and will run concurrently with the terms of the Agreement. This Exhibit is limited to the terms and conditions governing the provision of services in the fulfillment of contractual responsibilities to the State of Ohio (“State”) in the provision of health care services. The provisions set forth in this Exhibit shall be deemed to be part of the Program Contract, and are intended to comply with legislative and Regulatory Requirements of the State. To the extent that such laws and regulations are applicable and/or are not otherwise preempted by federal law, the provisions set forth in this Exhibit shall apply. The provisions of this Exhibit apply with respect to individuals who are enrolled in the Ohio Medicaid Program (hereinafter collectively referred to as “Members”).
12d.
This Executive Order prohibits the use of public funds to purchase services provided outside of the United States except under certain circumstances. Such services include the use of offshore programming or call centers. Additionally, Anthem and the Subcontractor shall not transfer personal health information to any location outside the United States or its territories.
of sex discrimination prohibited by Title VII of the Civil Rights Act of 1964, ORC section 4112.02, OAC 123:1-49, the Anti-Discrimination Policy in State Government Executive Order 2019-05D, or Agency policy.
Regulatory Requirements as unacceptable to ODM for any other reason, without limitation. If ODM determines that a part or the whole of the Agreement is unacceptable or incompatible as stated above, Anthem must amend the Agreement to ODM's satisfaction or seek a new Agreement.
$5,000,000 per occurrence, $10,000,000 aggregate. If a general aggregate limit applies, either the general aggregate limit must apply separately to this Agreement or the general aggregate limit must be twice the required occurrence limit. Defense costs shall be outside the policy limits.
as additional insured with respect to liability arising out of work or operations performed by or on behalf of the Subcontractor including materials, parts, or equipment furnished in connection with such work or operations. Coverage can be provided in the form of an endorsement to the Subcontractor's insurance.
endorsements are to be received and approved by Anthem and/or the Agency before work commences. However, failure to obtain the required documents prior to the work beginning shall not waive the Subcontractor's obligation to provide them. The Agency reserves the right to require complete, certified copies of all required insurance policies, including endorsements required by these specifications, at any time.
iii. Ohio Revised Code, ORC 173.20, 173.22, 2305.24, 2305.251,
3701.243, 3701.028, 4123.27, 5101.26, 5101.27, 5160.39, 5168.13, and
5165.88; and
iv. Corresponding Ohio Administrative Code rules.
Exhibit E-21
Appendix D. SUBCONTRACTOR BOILERPLATE
D.l SOUTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES REQUIRED SUBCONTRACT BOILERPLATE
The following language is required by the South Carolina Department of Health and Human Services (SCDHHS, hereafter referred to as the Department) as a condition of participation in the Medicaid program as a subcontractor of a Managed Care Organization (MCO). To the extent that any provision of this subcontract conflicts with any provision or requirement set forth within this Section, the Department required language shall be controlling. Any other provision in this agreement notwithstanding, in the event that the Department shall modify, amend, or otherwise change the required subcontract language, as set forth in the MCO Contract between the Department and the MCO, Subcontractor understands and agrees that the Department required subcontract boilerplate shall be amended to conform to the Department's requirements and standards, without the need for a signed, written amendment.
Action - As related to Grievance, either (1) the denial or limited authorization of a requested service, including the type or level of service; (2) the reduction, suspension, or termination of a previously authorized service; (3) the denial, in whole or in part, of payment for a service; (4) the failure to provide services in a timely manner, as defined by the Department; (5) the failure of the CONTRACTOR to act within the timeframes provided in §9.7.1 of the MCO Contract; or (6) for a resident of a rural area with only one CONTRACTOR, the denial of a Medicaid Managed Care Member's request to exercise his or her right, under 42 CFR §438.52(b)(2)(ii), to obtain services outside the CONTRACTOR's network.
Additional Services - A service(s) provided by the CONTRACTOR that is a non-covered service(s) by the South Carolina State Plan for Medical Assistance and is offered to Medicaid Managed Care Members in accordance with the standards and other requirements set forth in the Department's Medicaid Managed Care Contract that are outlined in another section of this Contract.
Administrative Services Contracts or Administrative Services Subcontracts - Are Subcontracts or agreement that include but are not limited to: 1) any function related to the management of the Medicaid Managed Care Contract with the Department; 2) Claims processing including pharmacy Claims; 3) credentialing including those for only primary source verification;
4) all Management Service Agreements; and 5) all Service Level Agreements (SLAs) with any Division of Subsidiary of a corporate parent owner.
Clean Claim - A Claim that can be processed without obtaining additional information from the Provider of the service or from a third party.
Continuity of Care - The continuous treatment for a condition (such as pregnancy) or duration of illness from the time of first contact with a healthcare Provider through the point of release or long-term maintenance.
Emergency Medical Condition - A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman and/or her unborn child) in serious jeopardy; serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
Emergency Services - Covered inpatient and outpatient services that are as follows: (1) furnished by a Provider that is qualified to furnish these services under Title 42 of the Code of Federal Regulations; and (2) needed to evaluate or stabilize an Emergency Medical Condition.
Federal Qualified Health Center (FQHC) - A South Carolina licensed health center certified by the Centers for Medicare and Medicaid Services that receives Public Health Services grants. An FQHC provides a wide range of primary care and enhanced services in a medically under-served area.
Grievance - An expression of dissatisfaction about any matter other than an Action. The term is also used to refer to the overall system that includes Grievances and appeals handled at the CONTRACTOR level. (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 Medicaid Managed Care Member's rights.)
Managed Care Organization (MCO) - An entity that has, or is seeking to qualify for, a Comprehensive Risk Contract that is (1) a Federally qualified HMO that meets the advance directive requirements of subpart I of 42 CFR Part 489; or (2) any public or private entity that meets the advance directives requirements and is determined to also meet the following conditions:
(a) makes the services it provides to its Medicaid Managed Care Members as accessible (in terms of timeliness, amount, duration, and scope) as those services are to other Medicaid recipients within the area serviced by the entity; and (b) meets the solvency standards of 42 CFR §438.116. This includes any of the entity's employees, affiliated Providers, agents, or CONTRACTORs.
Management Service Agreements - A type of Subcontract with an entity in which the CONTRACTOR delegates some or all of the comprehensive management and administrative services necessary for the operation of the CONTRACTOR.
Medically Necessary Service - Those medical services which: (a) are essential to prevent, diagnose, prevent the worsening of, alleviate, correct or cure medical conditions that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or aggravate a handicap, or result in illness or infirmity of a Medicaid Managed Care Member; (b) are provided at an appropriate facility and at the appropriate level of care for the treatment of the Medicaid Managed Care Member's medical condition; and, (c) are provided in accordance with generally accepted standards of medical practice.
Medicaid Managed Care Member - An eligible person(s) who is enrolled with a Department approved Medicaid Managed Care Organization (MCO, a.k.a. CONTRACTOR). For purpose of this Subcontract, Medicaid Managed Care Member shall include the patient, parent(s), guardian, spouse, or any other person legally responsible for the Medicaid Managed Care Member being served.
Minimum Subcontract Provision (MSP) - Minimum Service Provisions are detailed m subsection
Primary Care Provider (PCP) - The Provider, serving as the entry point into the health care system, for the Medicaid Managed Care Member responsible for providing primary care, coordinating and monitoring referrals to specialist care, authorizing hospital services, and maintaining Continuity of Care.
Provider - In accordance with 42 CFR § 400.203 Definitions specific to Medicaid, any individual or entity furnishing Medicaid services under a Provider agreement with the CONTRACTOR or the Medicaid agency. These may include the following:
Rural Health Clinic (RHC) - A South Carolina licensed Rural Health Clinic is certified by the Centers for Medicare and Medicaid Services and receiving Public Health Services grants. An RHC is eligible for state defined cost-based reimbursement from the Medicaid fee-for-service program. An RHC provides a wide range of primary care and enhanced services in a medically underserved area.
Service Level Agreement (SLA) - A type of Subcontract with a corporate owner or any of its Divisions or Subsidiaries that requires specific levels of service for administrative functions or services for the CONTRACTOR specifically related to fulfilling the CONTRACTOR's obligations to the Department under the terms of this Contract.
South Carolina Medicaid Network Provider - A Provider of healthcare services or products which includes but is not limited to an institution, facility, agency, person, corporation, partnership, practitioner, specialty physician, group or association approved and enrolled by the South Carolina Department of Health and Human Services, licensed and/or credentialed which accepts as payment in full for providing benefits to Medicaid Managed Care Members amounts pursuant to the CONTRACTOR's reimbursement provisions, business requirements and schedules.
Subcontract - A written agreement between the CONTRACTOR and a third party to perform a part of the CONTRACTOR's obligations as specified under the terms of the MCO Contract.
Subcontractor - Any organization or person who provides any functions or service for the CONTRACTOR specifically related to securing or fulfilling the CONTRACTOR's obligations to Department under the terms of the MCO Contract.
(120) Calendar Days prior to the effective date of termination. The date of termination will be at midnight on the last day of the month of termination.
D.1.4.2
D.1.4.3
D.1.4.4
D.1.4.5
D.1.4.6
As required by the South Carolina Attorney General (SCAG), in circumstances where the Subcontractor is a political subdivision of the State of South Carolina, or an affiliate organization, except as otherwise prohibited by law, neither Subcontractor nor the Department shall be liable for any claims, demands, expenses, liabilities and losses (including reasonable attorney's fees) which may arise out of any acts or failures to act by the other party, its employees or agents, in connection with the performance of services pursuant to this Subcontract.
It is expressly agreed that the CONTRACTOR, Subcontractor and agents, officers, and employees of the CONTRACTOR or Subcontractor in the performance of this Contract shall act in an independent capacity and not as officers and employees of the Department or the State of South Carolina. It is further expressly agreed that this Subcontract shall not be construed as a partnership or joint venture between the CONTRACTOR or Subcontractor and the Department and the State of South Carolina.
The Subcontractor shall recognize and abide by all state and federal laws, regulations and the Department's guidelines applicable to the provision of services under the Medicaid Managed Care Program.
The Subcontractor must comply with all applicable statutory and regulatory requirements of the Medicaid program and be eligible to participate in the Medicaid program.
This Subcontract shall be subject to and hereby incorporates by reference all applicable federal and state laws, regulations, policies, and revisions of such laws or regulations shall automatically be incorporated into the Subcontract as they become effective.
The Subcontractor represents and warrants that it has not been excluded from participation in the Medicare and/or Medicaid program pursuant to §§ 1128 (42 U.S.C. 1320a-7) (2001, as amended) or 1156 (42 U.S.C. 1320 c-5) (2001,
as amended) of the Social Security Act or is not otherwise barred from participation in the Medicaid and/or Medicare program.
The Subcontractor also represents and warrants that it has not been debarred, suspended or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from non-procurement activities under regulations issued under Executive Orders.
The Subcontractor shall not have a Medicaid contract with the Department that was terminated, suspended, denied, or not renewed as a result of any action of Center for Medicare and Medicaid Services (CMS), United States
Department of Health and Human Services (HHS), or the Medicaid Fraud Unit of the Office of the South Carolina Attorney General. Subcontractors who have been sanctioned by any state or federal controlling agency for Medicaid and/or Medicare fraud and abuse and are currently under suspension shall not be allowed to participate in the Medicaid Managed Care Program. In the event the Subcontractor is suspended, sanctioned or otherwise excluded during the term of this Subcontract, the Subcontractor shall immediately notify the CONTRACTOR in writing.
(10) years from the expiration date of the MCO Contract, including any MCO Contract extension(s). If any litigation, claim, or other actions involving the records have been initiated prior to the expiration of the ten (10) year period, the records shall be retained until completion of the action and resolution of all issues which arise from it or until the end of the ten (10) year period, whichever is later. If Subcontractor stores records on microfilm or microfiche, the Subcontractor must produce, at its expense, legible hard copy records upon the request of state or federal authorities, within fifteen (15) Calendar Days of the request.
data and information furnished by Subcontractors.
performance of its obligations under this Subcontract, including but not limited to, working papers related to the preparation of fiscal reports, health records, progress notes, charges, journals, ledgers, and electronic media, will be retained and safeguarded by the Subcontractor in accordance with the terms and conditions of this Contract.
§422.208 and 42 CFR §422.210 (2008, as amended).
EXHIBIT E-22
ADDENDUM BY AND BETWEEN
XXXXXXXX
AND AMERIGROUP CORPORATION
(AGREEMENT SHARES INDIVIDUALLY INDENTIFIABLE HEALTH INFORMATION AND MAY INVOLVE ADMINISTRATIVE SERVICES ENCOMPASSING ENROLLEE CONTACT)
The parties agree that this Addendum is a supplement to the XXXXXXXX (“Agreement”) for services provided by XXXXXXXX, the below identified Subcontractor (“Subcontractor”) to AMERIGROUP Tennessee, Inc. d/b/a AMERIGROUP Community Care (“Plan”), and is added to the Agreement because the subcontracted services may involve providing administrative services involving TennCare Enrollees and/or may involve contact with TennCare Enrollees, directly or indirectly. However, the subcontracted services will not include the provision of any TennCare Program Covered Services. The parties agree that services provided under this Agreement do involve the provision of TennCare enrollee individually identifying information to the Subcontractor or the receipt of TennCare enrollee individually identifying information by the Subcontractor.
This Addendum incorporates the terms and conditions of the CRA (as that term is defined below) governing the provision of services to or on behalf of the Plan in the fulfillment of the Plan’s contractual responsibilities to the State of Tennessee, Department of Finance and Administration, Division of Health Care Finance and Administration, Division of TennCare (“TennCare”) regarding all activities under the Contractor Risk Agreement between TennCare and the Plan (“CRA”). This Addendum and Agreement between the Plan and XXXXXXXX shall run concurrently with the terms of the CRA.
For the purposes of this Addendum:
an individual; and (i) identifies the individual; or (ii) with respect to which there is a reasonable basis to believe the information can be used to identify the individual.
Subcontractor warrants to TennCare and the Plan that Subcontractor is familiar with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Health Information for Electronic and Clinical Health Act (“HITECH”) and their accompanying regulations, and shall comply with all applicable HIPAA and HITECH requirements in the course of this Agreement. Subcontractor warrants that it will cooperate with TennCare and the Plan in the course of performance of the Agreement so that all parties will be in compliance with HIPAA and HITECH, including cooperation and coordination with TennCare privacy officers and other compliance officers required by HIPAA and HITECH. Subcontractor shall sign any documents that are reasonably necessary to keep TennCare, the Plan and Subcontractor in compliance with HIPAA and HITECH, including but not limited to business associate agreements.
Subcontractor understands that payment by the Plan or TennCare for any invoices and bills submitted by Subcontractor is conditioned upon the invoice or bill and the underlying transaction complying with Medicaid laws, regulations, and program requirements (including, but not limited to, the Federal anti-kickback statute at 42 United States Code (“U.S.C.”)_§ 1320a-7b(b), the Stark law at 42 U.S.C. § 1395nn, and federal requirements on disclosure, debarment and exclusion screening), and is conditioned on Subcontractor's compliance with all applicable conditions of participation in Medicaid. Subcontractor understands and agrees that each invoice or bill submitted by Subcontractor to the Plan or TennCare constitutes a certification that Subcontractor has complied with all applicable Medicaid laws, regulations and program instructions (including, but not limited to, the Federal anti-kickback statute and the Stark law), in connection with payment and the services provided under this Agreement.
TennCare enrollees, in person or via telephone, the Subcontractor shall comply with all requirements contained in the Agreement and the CRA pertaining to provision of services to TennCare enrollees.
authorized state or federal agency, access to their records. Said records shall be made available and furnished immediately upon request by Subcontractor for fiscal audit, medical audit, medical review, utilization review, and other periodic monitoring as well as for administrative, civil and criminal investigations or prosecutions upon the request of an authorized representative of the Plan, TennCare or authorized federal, state and Office of the Comptroller of the Treasury personnel, including, but not limited to, the OIG, the TBI MFCD, the DHHS OIG and the DOJ. Said records will be made available at no cost to the Plan or the requesting agency.
If Subcontractor is a “Provider” as defined in T.C.A. § 71-5-2503, then pursuant to T.C.A.
§ 63-2-101(i), Subcontractor is required to make available for inspection and copying to OIG and TBI MFCD, upon request, no later than by the close of business on the next business day, a complete set of all medical records requested in connection with an investigation being pursued by the agency or shall provide a compelling reason why the requested records cannot be produced; provided, that no such records shall be removed from the grounds of the Subcontractor's office without the Subcontractor's consent, unless OIG or TBI MFCD reasonably believes that the requested documents are about to be altered or destroyed.
If Subcontractor is not a “Provider” as defined in T.C.A. § 71-5-2503 and thus T.C.A. § 63-2-101(i) does not apply, such evaluation, inspection, review or request, when performed or requested, shall be performed with the immediate full cooperation of the Subcontractor, during normal business hours, except under special circumstances when after hour admission shall be allowed. Special circumstances shall be determined by the requesting agency. Upon request, the Subcontractor shall assist in such reviews including the provision of complete copies of medical records at no cost to the requesting agency. Subcontractor acknowledges that HIPAA does not bar disclosure of PHI to health oversight agencies, including, but not limited to TennCare, OIG, TBI MFCD, DHHS OIG and DOJ and their authorized agents. Any authorized state or federal agency or entity, including, but not limited to TennCare, OIG, TBI MFCD, DHHS OIG, DOJ, Office of the Comptroller of the Treasury, may use these records and information for medical audit, medical review, utilization review and administrative, civil or criminal investigations and prosecutions. However, for the purpose of the disclosures permitted by this provision, a health oversight activity does not include an investigation or other activity in which the individual is the subject of the investigation or activity and such investigation or other activity does not arise out of and is not directly related to:
Joint Activities or Investigations. Notwithstanding the above, if a health oversight activity or investigation is conducted in conjunction with an oversight activity or investigation relating to a claim for public benefits not related to health, the joint activity or investigation is considered a health oversight activity.
If the health plan, health care provider, or health care clearinghouse is a health oversight agency, the health plan, health care provider, or health care clearinghouse may use PHI for health oversight activities as permitted above.
TennCare, Center for Medicare and Medicaid Services (“CMS”), or their representatives shall, at all reasonable times, have the right to enter into the Subcontractor’s premises, or
such other places where duties of this Agreement are being performed, to inspect, monitor, or otherwise evaluate including periodic audits of the work being performed. The Subcontractor shall supply reasonable access to all facilities and assistance for TennCare’s representatives. The Subcontractor shall make available, for the purposes of an audit, evaluation, or inspection by the state, CMS, the DHHS Inspector General, the Comptroller General or their designees, its premises, physical facilities, equipment, books, records, contracts, computer, or other electronic systems relating to TennCare members. All inspections and evaluations shall be performed in such a manner as to minimize disruption of normal business.
TennCare rules and regulations, consent decrees or court orders, and revisions of such laws, regulations, consent decrees, or court orders shall automatically be incorporated into this Agreement, as they become effective. This compliance includes, but is not limited to, Sections A.2.19, A.2.21.7, A.2.25.5, A.2.25.6, A.2.25.8, A.2.25.10, E.13, E.28, E.36, and
D.7 of the CRA.
Compliance with the Privacy Rule, Security Rule, and Notification Rule;
The creation of and adherence to sufficient Privacy and Security Safeguards and Policies; Timely Reporting of Violations in the Access, Use and Disclosure of PHI; and
Timely Reporting of Privacy and/or Security Incidents.
the U.S. Secretary of Health and Human Services for the purposes of determining compliance with the HIPAA/HITECH regulations upon request;
identification of data; minimum necessary access; accounting of disclosures; enrollee’s right to amend, access, request restrictions; notice of privacy practices and right to file a complaint and breach notification;
U.S.C. § 3541, et seq.), and related National Institute of Standards and Technology guidelines. In addition, the Subcontractor shall have in place administrative, physical, and technical safeguards for data.
do so, the State, its contractors, agents and providers are not required to abide by the NIST guidelines.
U.S.C. § 3541, et seq.), and related National Institute of Standards and Technology (“NIST”) guidelines as outlined in the CMPPA and IEA governing this data, which provide the requirements that the SSA stipulates that the Subcontractor must follow with regard to use, treatment, and safeguarding data in the event data is exchanged with a federal information system.
C.F.R. § 2.32 (SAMHSA)
immediate family member of a state or federal officer or employee of the State of Tennessee as wages, compensation, or gifts in exchange for acting as officer, agent, employee, subcontractor, or consultant to Subcontractor in connection with any work contemplated or performed relative to this Agreement unless disclosed to the Commissioner, Tennessee Department of Finance and Administration. For the purposes of this Addendum and the Agreement, “immediate family member” shall mean a spouse or minor child(ren) living in the household.
This Agreement may be terminated by the Plan or TennCare, or the Plan may be subject to sanctions, including liquidated damages, under the CRA if it is determined that the Plan, its agents or employees or the Subcontractor, its agents or employees offered or gave gratuities of any kind to any state or federal officials or employees of the State of Tennessee or any immediate family member of a state or federal officer or employee of the State of Tennessee if the offering or giving of said gratuity is in contravention or violation of state or federal law. The Subcontractor certifies that no member or delegate of Congress, the United States Government Accountability Office, DHHS, CMS, or any other federal agency has or will benefit financially or materially from the Agreement. The Plan may impose sanctions, including liquidated damages, against the Subcontractor, to the extent that such sanctions are issued by TennCare to the Plan and from the Plan to the Subcontractor and are attributable to non-compliance or omission on the part of the Subcontractor. Subcontractor shall maintain adequate internal controls to detect, prevent, or disclose and mitigate conflict of interest issues under the CRA from occurring.
employees, agents or employees of Subcontractor’s agents offered or gave gratuities of any kind to any member or delegate of Congress, elected or appointed official or employee of the State of Tennessee, the United States General Accounting Office, the United States Department of Health and Human Services, CMS, or any other federal agency.
30.1 Subcontractor shall disclose lobbying activities using non-federal funds in accordance with 45 CFR Part 93.
§ 455.106 and establish policies and procedures to ensure that applicable criminal convictions are reported timely to the State.
The Subcontractor and its subcontractors, if any, agree to disclose business transaction information upon request and as otherwise specified in federal and state regulations.
Subcontractor shall screen its employees and contractors initially and on an ongoing monthly basis against Exclusion Lists (defined below) to determine whether any of them has been excluded from participation in Medicare, Medicaid, SCHIP, or any Federal health care programs (as defined in Section 1128B(f) of the Social Security Act) and not employ or contract with an individual or entity that has been excluded. . The word “individual” in this Section shall refer to all individuals listed on the disclosure form including both providers and non-providers such as board members, owners, agents, managing employees. Subcontractor shall be required to immediately report to the Plan any exclusion information discovered. Civil monetary penalties may be imposed against entities that employ or enter into contracts with excluded individuals or entities to provide items or services to TennCare members. Subcontractor shall report any exclusion under this Section to the Plan via fax to the attention of the Amerigroup Tennessee Plan Compliance Officer at 1-877-279-2445. Any unallowable funds made to excluded individuals as full or partial wages and/or benefits shall be refunded to and/or obtained by to TennCare and/or the Plan dependent upon the entity that identifies the payment of unallowable funds to excluded individuals.
If Subcontractor determines that a Screened Person has become an Ineligible Person, then Subcontractor shall take appropriate action to immediately remove such Screened Person from responsibility for, or involvement with, Subcontractor’s professional or business operations related to the Federal health care programs and shall remove such Screened Person from any position for which the Screened Person’s compensation or the items or services furnished, ordered, or prescribed by the Screened Person are paid in whole or part, directly or indirectly, by Federal health care programs or otherwise with Federal funds at least until such time as the Screened Person is reinstated into participation in the Federal health care programs. The aforementioned “immediate removal” requirement specifically supersedes any language that may be to the contrary in the Agreement. If Subcontractor determined that a Screened Person is an Ineligible Person charged with a criminal offense that falls within the ambit of 42 U.S.C. §§ 1320a-7(a) or is proposed for
exclusion during the Screened Person’s employment or contract term, Subcontractor shall take all appropriate actions to ensure that the responsibilities of that Screened Person have not and shall not adversely affect the quality of care rendered to any beneficiary, patient, or resident, or any claims submitted to any Federal health care program. Exclusion Lists – “Exclusion Lists” shall mean the U.S. Department of Health and Human Services' Office of Inspector General's List of Excluded individuals/Entities (located at http://www.oig.hhs.gov) and the General Services Administration's List of Parties Excluded from Federal Programs (located at http://www.epls.gov). Ineligible Persons – “Ineligible Persons” shall mean any individual or entity who: (a) is, as of the date such Exclusion Lists are accessed by Subcontractor, excluded, debarred, suspended, or otherwise ineligible to participate in the Federal health care programs or in Federal procurement or non-procurement programs; or (b) has been convicted of a criminal offense that falls within the ambit of 42 U.S.C. § 1320a-7(a), but has not yet been excluded, debarred, suspended, or otherwise declared ineligible. For purposes of this Addendum and Agreement, the term “Ineligible person” shall also include an individual or entity that has been terminated by TennCare from the Tennessee Medicaid to SCHIP program for program Integrity reasons.
The Plan will not pay any claim submitted by a provider who is excluded from participation in Medicare, Medicaid, or SCHIP programs pursuant to Sections 1128 or 1156 of the Social Security Act or is otherwise not in good standing with TennCare. Furthermore, the Plan will not pay any claim submitted by a provider that is on payment hold under the authority of TennCare.
The Plan and Subcontractor shall collect the disclosure of ownership and health care- related criminal conviction information as required by 42 C.F.R. Part 455 and establish policies and procedures to ensure that applicable criminal convictions are reported timely to the State of Tennessee. Subcontractor shall submit routine disclosures in accordance with timeframes specified in 42 C.F.R. Part 455, Subpart B and TennCare policies and procedures, including at the time of initial contracting, contract renewal, at any time there is a change to any of the information on the disclosure form, at least once every three (3) years, and at anytime upon request by the Plan or TennCare. Plan shall screen its employees and contractors initially and on an ongoing monthly basis to determine whether any of them has been excluded from participation in Medicare, Medicaid, SCHIP, or any Federal health care programs (as defined in Section 1128B(f) of the Social Security Act) and not employ or contract with an individual or entity that has been excluded. The results of said screenings shall be provided to TennCare on a monthly basis. The word “contractors” in this Section shall refer to all individuals listed on the disclosure form including providers and non-providers such as board members, owners, agents, managing employees, etc.
EXHIBIT E-23
ADDENDUM
BY AND BETWEEN
XXXXXXXX
AND AMERIGROUP CORPORATION
(AGREEMENT FOR ADMINISTRATIVE SERVICES THAT INVOLVES SHARING INDIVIDUALLY INDENTIFIABLE HEALTH INFORMATION THAT DOES NOT ENCOMPASS ENROLLEE CONTACT)
The parties agree that this Addendum is a supplement to the XXXXXXXX (“Agreement”) for services provided by XXXXXXXX, the below identified Subcontractor (“Subcontractor”) to AMERIGROUP Tennessee, Inc. d/b/a AMERIGROUP Community Care (“Plan”), and is added to the Agreement because the subcontracted services may involve providing administrative services involving TennCare Enrollees. However, the subcontracted services will not include the provision of any TennCare Program Covered Services or contact with TennCare enrollees. The parties agree that services provided under this Agreement do involve the provision of TennCare enrollee individually identifying information to the Subcontractor or the receipt of TennCare enrollee individually identifying information by the Subcontractor.
This Addendum incorporates the terms and conditions of the CRA (as that term is defined below) governing the provision of services to or on behalf of the Plan in the fulfillment of the Plan’s contractual responsibilities to the State of Tennessee, Department of Finance and Administration, Division of Health Care Finance and Administration, Division of TennCare (“TennCare”) regarding all activities under the Contractor Risk Agreement between TennCare and the Plan (“CRA”). This Addendum and Agreement between the Plan and XXXXXXXX shall run concurrently with the terms of the CRA.
For the purposes of this Addendum:
Subcontractor warrants to TennCare and the Plan that Subcontractor is familiar with the requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Health Information for Electronic and Clinical Health Act (“HITECH”) and their accompanying regulations, and shall comply with all applicable HIPAA and HITECH requirements in the course of this Agreement. Subcontractor warrants that it will cooperate with TennCare and the Plan in the course of performance of the Agreement so that all parties will be in compliance with HIPAA and HITECH, including cooperation and coordination with TennCare privacy officers and other compliance officers required by HIPAA and HITECH. Subcontractor
shall sign any documents that are reasonably necessary to keep TennCare, the Plan and Subcontractor in compliance with HIPAA and HITECH, including but not limited to business associate agreements.
Subcontractor understands that payment by the Plan or TennCare for any invoices and bills submitted by Subcontractor is conditioned upon the invoice or bill and the underlying transaction complying with Medicaid laws, regulations, and program requirements (including, but not limited to, the Federal anti-kickback statute at 42 United States Code (“U.S.C.”)_§ 1320a-7b(b), the Stark law at 42 U.S.C. § 1395nn, and federal requirements on disclosure, debarment and exclusion screening), and is conditioned on Subcontractor's compliance with all applicable conditions of participation in Medicaid. Subcontractor understands and agrees that each invoice or bill submitted by Subcontractor to the Plan or TennCare constitutes a certification that Subcontractor has complied with all applicable Medicaid laws, regulations and program instructions (including, but not limited to, the Federal anti-kickback statute and the Stark law), in connection with payment and the services provided under this Agreement.
for administrative, civil and criminal investigations or prosecutions upon the request of an authorized representative of the Plan, TennCare or authorized federal, state and Office of the Comptroller of the Treasury personnel, including, but not limited to, the OIG, the TBI MFCD, the DHHS OIG and the DOJ. Said records will be made available at no cost to the Plan or the requesting agency.
If Subcontractor is a “Provider” as defined in T.C.A. § 71-5-2503, then pursuant to T.C.A.
§ 63-2-101(i), Subcontractor is required to make available for inspection and copying to OIG and TBI MFCD, upon request, no later than by the close of business on the next business day, a complete set of all medical records requested in connection with an investigation being pursued by the agency or shall provide a compelling reason why the requested records cannot be produced; provided, that no such records shall be removed from the grounds of the Subcontractor's office without the Subcontractor's consent, unless OIG or TBI MFCD reasonably believes that the requested documents are about to be altered or destroyed.
If Subcontractor is not a “Provider” as defined in T.C.A. § 71-5-2503 and thus T.C.A. § 63-2-101(i) does not apply, such evaluation, inspection, review or request, when performed or requested, shall be performed with the immediate full cooperation of the Subcontractor, during normal business hours, except under special circumstances when after hour admission shall be allowed. Special circumstances shall be determined by the requesting agency. Upon request, the Subcontractor shall assist in such reviews including the provision of complete copies of medical records at no cost to the requesting agency. Subcontractor acknowledges that HIPAA does not bar disclosure of PHI to health oversight agencies, including, but not limited to TennCare, OIG, TBI MFCD, DHHS OIG and DOJ and their authorized agents. Any authorized state or federal agency or entity, including, but not limited to TennCare, OIG, TBI MFCD, DHHS OIG, DOJ, Office of the Comptroller of the Treasury, may use these records and information for medical audit, medical review, utilization review and administrative, civil or criminal investigations and prosecutions. However, for the purpose of the disclosures permitted by this provision, a health oversight activity does not include an investigation or other activity in which the individual is the subject of the investigation or activity and such investigation or other activity does not arise out of and is not directly related to:
Joint Activities or Investigations. Notwithstanding the above, if a health oversight activity or investigation is conducted in conjunction with an oversight activity or investigation relating to a claim for public benefits not related to health, the joint activity or investigation is considered a health oversight activity.
If the health plan, health care provider, or health care clearinghouse is a health oversight agency, the health plan, health care provider, or health care clearinghouse may use PHI for health oversight activities as permitted above.
TennCare, Center for Medicare and Medicaid Services (“CMS”), or their representatives shall, at all reasonable times, have the right to enter into the Subcontractor’s premises, or such other places where duties of this Agreement are being performed, to inspect, monitor,
or otherwise evaluate including periodic audits of the work being performed. The Subcontractor shall supply reasonable access to all facilities and assistance for TennCare’s representatives. The Subcontractor shall make available, for the purposes of an audit, evaluation, or inspection by the state, CMS, the DHHS Inspector General, the Comptroller General or their designees, its premises, physical facilities, equipment, books, records, contracts, computer, or other electronic systems relating to TennCare members. All inspections and evaluations shall be performed in such a manner as to minimize disruption of normal business.
TennCare rules and regulations, consent decrees or court orders, and revisions of such laws, regulations, consent decrees, or court orders shall automatically be incorporated into this Agreement, as they become effective. This compliance includes, but is not limited to, Sections A.2.19, A.2.21.7, A.2.25.5, A.2.25.6, A.2.25.8, A.2.25.10, E.13, E.28, E.36, and
D.7 of the CRA.
24.1. The Plan and Subcontractor, individually, shall indemnify and hold harmless the State of Tennessee (“State”), as well as its officers, agents, and employees (hereinafter the “Indemnified Parties”), from all claims, losses or suits incurred by or brought against the Indemnified Parties as a result of the failure of the Plan or Subcontractor to comply with the terms of this Agreement. The State shall give the Plan or Subcontractor written notice of each such claim or suit and full right and opportunity to conduct the Plan’s or Subcontractor’s own defense thereof, together with full information and all reasonable cooperation; but the State does not hereby accord to the Plan or Subcontractor, through its
attorneys, any right(s) to represent the State of Tennessee in any legal matter, such right being governed by TCA § 8- 6-106.
Compliance with the Privacy Rule, Security Rule, and Notification Rule;
The creation of and adherence to sufficient Privacy and Security Safeguards and Policies;
Timely Reporting of Violations in the Access, Use and Disclosure of PHI; and Timely Reporting of Privacy and/or Security Incidents.
Compliance includes meeting all required transaction formats and code sets with the specified data sharing agreements required under the regulations;
U.S.C. § 3541, et seq.), and related National Institute of Standards and Technology guidelines. In addition, the Subcontractor shall have in place administrative, physical, and technical safeguards for data.
U.S.C. § 3541, et seq.), and related National Institute of Standards and Technology (“NIST”) guidelines as outlined in the CMPPA and IEA governing this data, which provide the requirements that the SSA stipulates that the Subcontractor must follow with regard to use, treatment, and safeguarding data in the event data is exchanged with a federal information system.
C.F.R. § 2.32 (SAMHSA)
This Agreement may be terminated by the Plan or TennCare, or the Plan may be subject to sanctions, including liquidated damages, under the CRA if it is determined that the Plan, its agents or employees or the Subcontractor, its agents or employees offered or gave gratuities of any kind to any state or federal officials or employees of the State of Tennessee or any immediate family member of a state or federal officer or employee of the State of Tennessee if the offering or giving of said gratuity is in contravention or violation of state or federal law. The Subcontractor certifies that no member or delegate of Congress, the United States Government Accountability Office, DHHS, CMS, or any other federal agency has or will benefit financially or materially from the Agreement. The Plan may impose sanctions, including liquidated damages, against the Subcontractor, to the extent that such sanctions are issued by TennCare to the Plan and from the Plan to the Subcontractor and are attributable to non-compliance or omission on the part of the Subcontractor. Subcontractor shall maintain adequate internal controls to detect, prevent, or disclose and mitigate conflict of interest issues under the CRA from occurring.
DHHS, CMS, or any other federal agency has or will benefit financially or materially from this Agreement.
30.1 Subcontractor shall disclose lobbying activities using non-federal funds in accordance with 45 CFR Part 93.
§ 455.106 and establish policies and procedures to ensure that applicable criminal convictions are reported timely to the State.
The Subcontractor and its subcontractors, if any, agree to disclose business transaction information upon request and as otherwise specified in federal and state regulations.
any, shall provide written notification to the Plan and the TennCare Office of Program Integrity (OPI) of overpayments identified by the Subcontractor and, when it is applicable, return overpayments within sixty (60) days from the date the overpayment is identified.
Overpayments that are not returned within sixty (60) days from the date the overpayment was identified may result in a penalty pursuant to state or federal law.
Subcontractor shall screen its employees and contractors initially and on an ongoing monthly basis against Exclusion Lists (defined below) to determine whether any of them has been excluded from participation in Medicare, Medicaid, SCHIP, or any Federal health care programs (as defined in Section 1128B(f) of the Social Security Act) and not employ or contract with an individual or entity that has been excluded. . The word “individual” in this Section shall refer to all individuals listed on the disclosure form including both providers and non-providers such as board members, owners, agents, managing employees. Subcontractor shall be required to immediately report to the Plan any exclusion information discovered. Civil monetary penalties may be imposed against entities that employ or enter into contracts with excluded individuals or entities to provide items or services to TennCare members. Subcontractor shall report any exclusion under this Section to the Plan via fax to the attention of the Amerigroup Tennessee Plan Compliance Officer at 1-877-279-2445. Any unallowable funds made to excluded individuals as full or partial wages and/or benefits shall be refunded to and/or obtained by to TennCare and/or the Plan dependent upon the entity that identifies the payment of unallowable funds to excluded individuals.
If Subcontractor determines that a Screened Person has become an Ineligible Person, then Subcontractor shall take appropriate action to immediately remove such Screened Person from responsibility for, or involvement with, Subcontractor’s professional or business operations related to the Federal health care programs and shall remove such Screened Person from any position for which the Screened Person’s compensation or the items or services furnished, ordered, or prescribed by the Screened Person are paid in whole or part, directly or indirectly, by Federal health care programs or otherwise with Federal funds at least until such time as the Screened Person is reinstated into participation in the Federal health care programs. The aforementioned “immediate removal” requirement specifically supersedes any language that may be to the contrary in the Agreement. If Subcontractor determined that a Screened Person is an Ineligible Person charged with a
criminal offense that falls within the ambit of 42 U.S.C. §§ 1320a-7(a) or is proposed for exclusion during the Screened Person’s employment or contract term, Subcontractor shall take all appropriate actions to ensure that the responsibilities of that Screened Person have not and shall not adversely affect the quality of care rendered to any beneficiary, patient, or resident, or any claims submitted to any Federal health care program. Exclusion Lists – “Exclusion Lists” shall mean the U.S. Department of Health and Human Services' Office of Inspector General's List of Excluded individuals/Entities (located at http://www.oig.hhs.gov) and the General Services Administration's List of Parties Excluded from Federal Programs (located at http://www.epls.gov). Ineligible Persons – “Ineligible Persons” shall mean any individual or entity who: (a) is, as of the date such Exclusion Lists are accessed by Subcontractor, excluded, debarred, suspended, or otherwise ineligible to participate in the Federal health care programs or in Federal procurement or non-procurement programs; or (b) has been convicted of a criminal offense that falls within the ambit of 42 U.S.C. § 1320a-7(a), but has not yet been excluded, debarred, suspended, or otherwise declared ineligible. For purposes of this Addendum and Agreement, the term “Ineligible person” shall also include an individual or entity that has been terminated by TennCare from the Tennessee Medicaid to SCHIP program for program Integrity reasons.
The Plan will not pay any claim submitted by a provider who is excluded from participation in Medicare, Medicaid, or SCHIP programs pursuant to Sections 1128 or 1156 of the Social Security Act or is otherwise not in good standing with TennCare. Furthermore, the Plan will not pay any claim submitted by a provider that is on payment hold under the authority of TennCare.
The Plan and Subcontractor shall collect the disclosure of ownership and health care- related criminal conviction information as required by 42 C.F.R. Part 455 and establish policies and procedures to ensure that applicable criminal convictions are reported timely to the State of Tennessee. Subcontractor shall submit routine disclosures in accordance with timeframes specified in 42 C.F.R. Part 455, Subpart B and TennCare policies and procedures, including at the time of initial contracting, contract renewal, at any time there is a change to any of the information on the disclosure form, at least once every three (3) years, and at anytime upon request by the Plan or TennCare. Plan shall screen its employees and contractors initially and on an ongoing monthly basis to determine whether any of them has been excluded from participation in Medicare, Medicaid, SCHIP, or any Federal health care programs (as defined in Section 1128B(f) of the Social Security Act) and not employ or contract with an individual or entity that has been excluded. The results of said screenings shall be provided to TennCare on a monthly basis. The word “contractors” in this Section shall refer to all individuals listed on the disclosure form including providers and non-providers such as board members, owners, agents, managing employees, etc.
Subcontractor on its obligations and to communicate any other pertinent information. The two (2) semi-annual contacts shall be conducted face-to-face or conducted via telephone, face-to-face, or conducted via telephone.
EXHIBIT E-24
TENNESSEE
HIPAA BUSINESS ASSOCIATE AGREEMENT
THIS HIPAA BUSINESS ASSOCIATE AGREEMENT (“Agreement”) is between
AMERIGROUP Tennessee, Inc., (“XXXXXXXX” or Covered Entity”) located at 22 Century Boulevard, Suite 310, Nashville, Tennessee 37214, XXXXXXXX” (“Business Associate”), located at XXXXXXXX”, including all office locations and other business locations at which Business Associate data may be used or maintained. Covered Entity and Business Associate may be referred to herein individually as “Party” or collectively as “Parties.”
BACKGROUND
The Parties acknowledge that they are subject to the Privacy and Security Rules (45 C.F.R. Parts 160 and 164) promulgated by the United States Department of Health and Human Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Public Law 104-191, and as amended by the final rule modifying the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health Act (HITECH). If Business Associate provides services to Covered Entity pursuant to one or more contractual relationships, said Agreements are detailed below and hereinafter referred to as “Service Agreements.”
LIST OF AGREEMENTS AFFECTED BY THIS HIPAA BUSINESS ASSOCIATE AGREEMENT:
XXXXXXXX
In the course of performing services under a Service Agreement, Business Associate may come into contact with, use, or disclose Protected Health Information (“PHI”). Said Service Agreements are hereby incorporated by reference and shall be taken and considered as a part of this document the same as if fully set out herein.
In accordance with the federal privacy and security rules and regulations set forth at 45 C.F.R. Part 160 and Part 164, Subparts A, C, D and E, which require Covered Entity to have a written memorandum with each of its Business Associates, the Parties wish to establish satisfactory assurances that Business Associate will appropriately safeguard PHI that Business Associate may receive (if any) from or on behalf of Covered Entity, and, therefore, execute this Agreement.
All capitalized terms used, but not otherwise defined, in this Agreement shall have the same meaning as those terms defined in 45 C.F.R. Parts 160 through 164 or other applicable law or regulation. A reference in this Agreement to a section in the Privacy or Security Rule means the section as in effect or as amended.
set forth specifically, it is as if set forth in this Agreement in its entirety and is effective as of the Applicable Effective Date, and as amended.
Unsecured PHI immediately upon becoming aware of the Breach, and in no case later than 48 hours after discovery.
C.F.R. § 164.526, regarding an Individual’s request to amend PHI. The Business Associate shall make the amendment promptly in the time and manner designated by Covered Entity, but shall have thirty
(30) days’ notice from Covered Entity to complete the amendment to the Individual’s PHI and to notify the Covered Entity upon completion.
each subsequent request for an accounting by the same Individual if he/she is provided notice and the opportunity to modify his/her request. Such charges shall not exceed any applicable State statutes or rules.
3.4.1 Business Associate identifies the following key contact persons for all matters relating to this Agreement:
XXXXXXXX |
|
XXXXXXXX |
|
XXXXXXXX |
|
XXXXXXXX |
|
XXXXXXXX |
|
Business Associate shall notify Covered Entity of any change in these key contacts during the term of this Agreement in writing within ten (10) business days.
Lori Stiffler
Director, TN Compliance Phone: 949-526-3249
Fax: 866-796-4532
Email: tnregsvcs@amerigroup.com
to share PHI with Business Associate’s affiliates or contractors except for the purposes of the Service Agreement(s) between the Covered Entity and Business Associate(s) identified in the “LIST OF AGREEMENTS AFFECTED BY THIS HIPAA BUSINESS ASSOCIATE
AGREEMENT” on page one (1) of this Agreement.
provides access to Protected Health Information.
either return and/or destroy all PHI and other confidential information received from Covered Entity or created or received by Business Associate on behalf of Covered Entity. This provision applies to all confidential information regardless of form, including but not limited to electronic or paper format. This provision shall also apply to PHI and other confidential information in the possession of sub-contractors or agents of Business Associate.
PHI and limit further uses and disclosures of such PHI to those purposes that make the return or destruction unfeasible, for so long as Business Associate maintains such PHI.
Notifications relative to Sections 2.8 and 3.4 of this Agreement must also be reported to the Privacy Officer pursuant to Section 3.5.
COVERED ENTITY: BUSINESS ASSOCIATE:
Lori Stiffler XXXXXXXX
Director, TN Compliance XXXXXXXX
Phone: 949-526-3249 Phone: XXXXXXXX
Fax: 866-796-4532 Fax: XXXXXXXX
Email: tnregsvcs@amerigroup.com Email: XXXXXXXX
All instructions, notices, consents, demands, or other communications shall be considered effectively given as of the date of hand delivery; as of the date specified for overnight courier service delivery; as of three (3) business days after the date of mailing; or on the day the facsimile transmission is received mechanically by the facsimile machine at the receiving location and receipt is verbally confirmed by the sender.
except as specifically provided by, in, and through, existing administrative requirements of Tennessee State government and Services Agreement(s) referenced herein.
IN WITNESS WHEREOF, the Parties execute this Agreement to be valid and enforceable from the last date set out below:
By: By: XXXXXXXX
[TYPED NAME] XXXXXXXX
Date: Date: XXXXXXXX
XXXXXXXX |
|
XXXXXXXX |
|
AMERIGROUP TENNESSEE, INC. NAME: XXXXXXXX
22 Century Boulevard, Suite 310
Nashville, Tennessee 37214
Phone: 949-526-3249 Phone: XXXXXXXX
Fax: 886-796-4532 Fax: XXXXXXXX
Email:tnregsvcs@amerigroup.com Email: XXXXXXXX
EXHIBIT E-25
AMERIGROUP TEXAS STATE EXHIBIT
This Exhibit will supplement the agreement between AMERIGROUP Corporation, Affiliates and Subcontractor effective upon approval (the “Agreement”) and will run concurrently with the terms of the Agreement. This Exhibit is limited to the terms and conditions governing provisions of services to or on behalf of AMERIGROUP Texas, Inc., Amerigroup Insurance Company, Inc., and Affiliates (collectively, “MCO) in the fulfillment of MCO’s contractual responsibilities to the Texas Health and Human Services Commission in the provisions of health care services to Medicaid and CHIP members, including but not limited to contracts for STAR, STAR+PLUS, STAR Kids and CHIP members. This Exhibit is effective only upon the approval of the Texas Health and Human Services Commission.
EXHIBIT DEFINITIONS
For the purposes of this Exhibit, the following definitions shall apply:
EXHIBIT PROVISIONS
The provisions of this Exhibit supersede any language to the contrary which may appear elsewhere in the Agreement.
The parties agree to abide by all of the following specific terms:
cessation of operations, Subcontractor’s sole recourse is against MCO or AMERIGROUP through the bankruptcy or receivership estate of MCO or AMERIGROUP.
C.F.R. § 438.16, base data in 42 C.F.R. § 438.5(c), MLR reports under 42 C.F.R. § 438.8(k), and the data, information, and documentation specified under 42 C.F.R. § 438.604, § 438.606, § 438.608, and § 438.610 for a period no less than ten10 years from the expiration date of this Contract or from the date of the completion of any audit, whichever is later.
a. Additionally, Subcontractors agree to, retain all records in accordance with any litigation hold that is provided to them by HHSC and actively participate in the discovery process if required to do so, at no additional charge to HHSC. Litigation holds may require the MCO or its Subcontractors to keep the records longer than other records retention schedules. The MCO will be required to retain all records subject to the litigation hold until notified by HHSC when the litigation hold ends and then other approved records retention schedule(s) may resume. If MCO or its Subcontractors fail to retain the pertinent records after receiving a litigation hold from HHSC, the MCO agrees to pay to HHSC all damages, costs, and expenses incurred
Subcontractor must confirm the eligibility of all persons employed by the Subcontractor to perform duties within Texas and all persons, including subcontractors, assigned by the MCO to perform work pursuant to the Contract. The MCO may not knowingly have a relationship with the following:
§438.610(c).
EXHIBIT E-26
VIRGINIA STATE-SPECIFIC REQUIREMENTS
This Exhibit is attached to and incorporated into the Agreement and is applicable solely to Vendor Services provided to or for the administration of Medicaid programs in the Commonwealth of Virginia. To the extent any provisions herein conflict with the provisions set forth in the Agreement, the provisions in this Exhibit and the provisions in the contract(s) between the Virginia Department of Medical Assistance Services and HealthKeepers, Inc., which are incorporated by reference, shall control for those Vendor Services provided to Medicaid Members as defined herein.
Definitions:
Medicaid Required Terms:
Vendor agrees to abide by all applicable provisions of the contract(s) between HMO and the DMAS (hereafter collectively referred to as "HMO’s Medicaid Contract"). Vendor’s compliance with the HMO’s Medicaid Contract specifically includes, but is not limited to, the following requirements as they relate to Medicaid Members and services provided to Medicaid Members:
supported by an effective retrieval system which meets legal requirements to support litigation, and to be admissible into evidence in any court of law.
which payment has been made even if Vendor becomes insolvent until such time as Medicaid Members are withdrawn from assignment to Vendor.
455.106 (regarding disclosure by Vendors of ownership and control information and disclosure of information on a Vendor's owners' and other persons' conviction of criminal offenses against Medicare, Medicaid, or Title XX services program) and will agree to provide required disclosures at the time of initial contract, upon contract renewal, and/or upon request by the HMO. The Vendor further agrees to notify the HMO within fourteen
(14) days of any changes to the required disclosures.
period, the Vendor shall notify the HMO contract administrator within 40 days prior to the change occurring.
Technology for Economic and Clinical Health (HITECH) Act and the Genetic Information Nondiscrimination Act.
remediation of any unsatisfactory practice constitute acceptance of such practice or waiving of the DMAS’s enforcement right;
x. COV SEC 501-11.309 (or latest) IT Information Security Standard
EXHIBIT E-27
WASHINGTON STATE-SPECIFIC REQUIREMENTS AMERIGROUP WASHINGTON, INC.
EXHIBIT
with SPECIFICATIONS ON LIQUIDATED DAMAGES as outlined the Contract.
such providers must agree to abide by the provisions of WAC 284-43-320 (a), (b), (c), (d), and (e).
provision, or of the Risk provision found in the Definitions Section of this Contract, the Contractor shall establish, enforce and monitor solvency requirements that provide assurance of the Subcontractor's ability to meet its obligations.
Subcontractor by a Contracted Subcontractor, Subcontractor shall be responsible for ensuring that: (i) such Contracted Subcontractor furnishes such services in compliance with all of Subcontractor’s obligations under this Agreement and in accordance with WAC 284-43-300 including, without limitation, maintaining required insurance, and holding Covered Persons harmless for the cost of any services or supplies provided by Contracted Subcontractors to Covered Persons; and (ii) all subcontractor requirements are propagated downward into any other lower tiered subcontracts. (45 C.F.R. 92.35). No assignment of a subcontract shall take effect without HCA's written agreement. Subcontractor shall have written policies for all employees, subcontractors, agents, or providers that provide detailed information about the False Claims Act and other f federal and state laws described in Section 1902(a)(68) of the Social Security Act, and the Washington false claims statutes, chapters 74.66 RCW and RCW 74.09.210, including information about rights of employees to be protected as whistleblowers, and the criminal statutes found in chapter 74.09 sections .230 through .280 RCW.
participation under any federal or state health benefits program, including without limitation the Medicaid or Medicare programs. The Subcontractor shall not knowingly have an employment, consulting, or any other contractual agreement with a person or entity for the provision of items or services that are significant and material to this Agreement, when the person or entity has been debarred or suspended from participating in 12.11.3.1 Procurement activities under the Federal Acquisition Regulation; or
12.11.3.2 Non-procurement activities under regulations issued pursuant to Executive Order No. 12549 or under guidelines implementing such order.
reasons described in the Agreement, MCO shall within 30 calendar days, or any shorter timeframe as authorized by law or court order, make available, to the Program, or its designated representative, in a usable form, any and all records, whether medical or financial, related to MCO’s and Subcontractor’s activities undertaken pursuant to this Agreement. The provision of such records shall be at no expense to the Program.
For the term of this Contract and three (3) years following its termination Contractor shall maintain insurance to cover costs incurred in connection with a security incident, privacy y Breach, or potential compromise of Data including:
iv. Subcontractor shall disclose to HCA upon contract execution [42 C.F.R. 455.104(c)(1)(ii)], upon request during the re-validation of enrollment process under 42 C.F.R. 455.414 [42 C.F.R. 455.104(c)(1)(iii)], and within thirty-five
(35) business days after any change in ownership of the subcontractor or provider (42 C.F.R. 455.104(c)(1)(iv)).
If Data access is to be provided to Subcontractor under this Agreement, Subcontractor acknowledges and agrees to all of the HCA Data security terms, conditions and
requirements set forth in Attachment A to the Washington State-specific requirements.
ATTACHMENT A
HCA DATA USE, SECURITY, AND CONFIDENTIALITY REQUIREMENTS
Definitions:
1.1 “Authorized User” means an individual or individuals with an authorized business need to access Confidential Information under the Agreement.
following character classes: upper case letters; lower case letters; numerals; and special characters, such as an asterisk, ampersand or exclamation point.
dispute. Overpayment can also mean a payment from the Contractor to a provider or subcontractor to which the provider or subcontractor is not legally entitled. (42 C.F.R. 438.2 and RCW 41.05A.010).
laptops/notebook/tablet computers. If used to store Confidential Information, devices should be Federal Information Processing Standards (FIPS) Level 2 compliant.
delivery of Confidential Information to the authorized and intended recipient, and when the sender receives confirmation of delivery from the authorized and intended recipient of Confidential Information.
acknowledgement of receipt; (2) United States Postal Service (“USPS”) first class mail, or USPS delivery services that include Tracking, such as Certified Mail, Express Mail or Registered Mail; (3) commercial delivery services (e.g. FedEx, UPS, DHL) which offer
tracking and receipt confirmation; and (4) the Washington State Campus mail system. For electronic transmission, the Washington State Governmental Network (SGN) is a Trusted System for communications within that Network.
Data Classification:
Standards No. 141.10 in the State Technology Manual at https://ocio.wa.gov/policies/141-securing-information-technology-assets/14110-securing- information-technology-assets.
The Data that is the subject of the Contract is classified as Category 4 – Confidential Information Requiring Special Handling. Category 4 Data is information that is
specifically protected from disclosure and for which:
Constraints on Use of Data:
Agreement only to carry out the purpose of the Agreement. Any ad hoc analyses or other use or reporting of the Data is not permitted without MCO’s or HCA’s prior written
consent.
accordance with 42 C.F.R. § 2.32, this Data has been disclosed from records protected by federal confidentiality rules (42 C.F.R. Part 2). The federal rules prohibit Receiving Party from making any further disclosure of the Data that identifies a patient as having or
having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless
further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 C.F.R. Party 2. A general authorization for the release of medical or other information is NOT sufficient for this
purpose (42 C.F.R. § 2.31). The federal rules restrict any use of the SUD Data to
investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at 42 C.F.R. § 2.12(c)(5) and § 2.65.
Subcontractor, Subcontractor must provide MCO with thirty (30) calendar days’ advance notice and opportunity for review and advisement to ensure alignment and coordination between Subcontractor and HCA data governance initiatives. Subcontractor will provide notice to Amerigroup Washington, Inc., 705 5th Avenue South, Suite 300, Seattle, WA.
98104. The Notice to MCO will include:
individually identifiable and de- identified, regarding Enrollees, including claims data, shared with external entities, including but not limited to subcontractors and researchers.
Security of Data:
or federal law or regulation, or Data that MCO or HCA has identified as
confidential, against unauthorized use, access, disclosure, modification or loss. This duty requires the Subcontractor to employ reasonable security measures, which include restricting access to the Confidential Information by:
or other authentication mechanisms which provide equal or greater security, such as biometrics or smart cards. Systems that contain or provide access to Confidential Information must be located in an area that is accessible only to
authorized personnel, with access controlled through use of a key, card key, combination lock, or comparable
mechanism.
authentication method such as a physical token or biometrics;
Information must be protected by storing the records in a Secured Area that is accessible only to authorized personnel. When not in use, such records must be stored in a locked container, such as a
file cabinet, locking drawer, or safe, to which only authorized persons have access.
been compromised in the event of a security breach. MCO’s Data must be kept in one of the following ways:
disposed of as set out below, except as required to be maintained for compliance or accounting purposes. Media are to be destroyed using a method documented within NIST 800-88 (http://csrc.nist.gov/publications/PubsSPs.html).
Data Confidentiality and Non-Disclosure:
Confidential Information gained by reason of the Agreement for any purpose that is not directly connected with the purpose of the Agreement, except:
representative of the person who is the subject of the Confidential Information.
aware of the use restrictions and protection requirements of these sections before they gain access to the Data.
documentation available to MCO or HCA upon request.
Data Shared with Subcontractors:
6.1. If Data access is to be provided to a subcontractor under the Agreement, the
subcontractor must include all of the Data security terms, conditions and requirements set forth in these sections in any such subcontract. However, no subcontract will terminate Subcontractor's legal responsibility to MCO for any work performed under the
Agreement nor for oversight of any functions and/or responsibilities it delegates to any
subcontractor. Subcontractor must provide an attestation by January 31, each year that Subcontractor (and any subcontractors) meet, or continue to meet, the terms, conditions, and requirements in these sections.
Breach:
business days of discovery. If Subcontractor does not have full details, it will report what information it has, and provide full details within 15 business days of discovery. To the extent possible, these reports must include the following:
limited to 45 C.F.R. Part 164, Subpart D; RCW 42.56.590; RCW 19.255.010; or WAC 284-04-625.
(2) business days of determining notification must be sent to enrollees.
Data Breach Notification:
Agreement in compliance with HIPAA, the HIPAA Rules, and all applicable regulations as promulgated by the U.S. Department of Health and Human Services, Office for Civil Rights, as applicable. Subcontractor and Subcontractor’s subcontracts must fully
cooperate with MCO and HCA efforts to implement HIPAA requirements.
enforcement, or compliance action initiated by the Office for Civil Rights based on an allegation of violation of HIPAA or the HIPAA Rules and must inform MCO of the
outcome of that action. Subcontractor bears all responsibility for any penalties, fines, or sanctions imposed against Subcontractor or MCO for violations by Subcontractor of
HIPAA or the HIPAA Rules and for any sanction imposed against its subcontractors or agents for which it is found liable.
Inspection:
9.1. MCO reserves the right to monitor, audit, or investigate the use of Personal Information and PHI of Enrollees collected, used, or acquired by Subcontractor during the terms of the Agreement. All MCO or HCA representatives conducting onsite audits of
Subcontractor agree to keep confidential any patient- identifiable information which may be reviewed during the course of any site visit or audit.
Indemnification:
10.1. The Subcontractor agrees to indemnify and hold MCO and HCA and its employees
harmless from any damages related to the Subcontractor’s unauthorized use or release of Personal Information or PHI of Enrollees.
EXHIBIT E-28
DISTRICT OF COLUMBIA SPECIFIC REQUIREMENTS
AMERIGROUP DISTRICT OF COLUMBIA, INC.
THIS EXHIBIT (“Exhibit”) is made by and between Amerigroup District of Columbia, Inc. (“Amerigroup DC”), and “Subcontractor”.
RECITALS
Amerigroup DC and Subcontractor are parties to that certain vendor agreement (the “Subcontract”), and wish to addend said Subcontract as provided herein.
AGREEMENT
IN CONSIDERATION of the mutual promises set forth herein, in the Subcontract, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:
This Exhibit is limited to the terms and conditions governing the provision of services to or on behalf of Amerigroup DC’s fulfillment of Amerigroup DC’s contractual responsibilities to the District of Columbia Department of Health Care Finance (“DHCF”) regarding all activities under the Managed Care Program, consisting of: the Medicaid eligible population enrolled in the District Healthy Families Program and the District Healthcare Alliance Program and Immigrant Children’s Program (“Contract”) between the DHCF and Amerigroup DC. This Exhibit will supplement the Subcontract between Amerigroup DC and Subcontractor and will run concurrently with the terms of the Subcontract.
Each provision of this Exhibit supersedes and shall be controlling over any conflicting terms that appear in the Subcontract.
For the purposes of this Exhibit:
Subcontracting Requirements
Amerigroup DC Responsibilities
CBE SUBCONTRACTING REQUIREMENTS
Each subcontracting submission to Agency shall include the following:
Within twenty-one (21) days of the date of award, the Contractor shall provide fully executed copies of all subcontracts identified in the subcontracting plan to the CO, CA, District of Columbia Auditor and the Director of DSLBD.
EXHIBIT E-29
West Virginia State-Specific Requirements - Subcontractors
As a subcontractor under the contract (hereafter referred to as the (“Medicaid/WVCHIP Contract”) between UNICARE Health Plan of West Virginia, Inc. (hereafter referred to as the “Contractor”) and the State of West Virginia Department of Health and Human Resources Bureau for Medical Services (“BMS”) and West Virginia Children’s Health Insurance Program (“CHIP”) for the provision of risk-based comprehensive health services to enrollees in the West Virginia Mountain Health Trust program or any other similar program (“Medicaid Managed Care Program”) administered by BMS (hereafter referred to as “Members”, “Covered Individuals”, or “Covered Population“), the Subcontractor agrees to abide by all applicable provisions of the terms of the Medicaid/WVCHIP Contract, including but not limited to the following.
27. The Contractor, the State of West Virginia, CMS, the Office of the Inspector General, and any other legally authorized governmental entity shall monitor the Subcontractor’s performance on an ongoing basis and subject it to formal review according to a periodic schedule established by BMS/CHIP, consistent with industry standards or West Virginia laws and regulations. Additionally, BMS/CHIP, the United States Department of Health and Human Services, the State of West Virginia, CMS, the Office of the Inspector General, the Comptroller General, their designees, and any other legally authorized governmental entity are, in accordance with the terms set forth in this Section, authorized to evaluate through inspection or other means including record/documentation audits, the quality, appropriateness, and timeliness of services performed under the subcontract at any time. When deficiencies or areas for improvement are identified, the Contractor and the Subcontractor must take corrective action. The activities and report responsibilities delegated to the Subcontractor may be revoked in whole or in part or other sanctions may be invoked if the Subcontractor does not satisfy standards set forth herein or take the corrective action set forth herein. The Subcontractor must agree to comply with a monitoring plan developed by Contractor.
28. As a subcontractor to the Contractor under its contract with BMS/CHIP, the Subcontractor further agrees as follows:
a. The Subcontractor agrees that the following are ineligible physicians/groups/providers:
1. An individual/entity that is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued under Executive Order No.12549 or under guidelines implementing Executive Order No. 12549.
2. An individual/entity that is an affiliate, as defined in the Federal Acquisition Regulation, of an individual/entity that meets the requirements of subsection a.viii.A above.
The affiliate relationship is described as follows:
• A director, officer, or partner of the individual/entity
• A person with beneficial ownership of five percent or more of the individual’s/entity’s equity.
• A person with an employment, consulting or other arrangement with the Subcontractor who performs any part of Subcontractor’s obligations under its contract with Contractor.
Please refer to the Federal Debarment List located at: www.sam.gov or for a listing of federally debarred and suspended individuals/entities and the Federal List of Excluded Individuals/ Entities (LEIE) database, available at http://www.oig.hhs.gov/fraud/exclusions/exclusions_list.asp.
i. Notification of Breach. The Subcontractor shall notify the Agency and, unless otherwise directed by the Agency in writing, the WV Office of Technology, immediately by e-mail or web form upon the discovery of any Breach of unsecured PHI; or within 24 hours by e-mail or web form of any suspected Security Incident, intrusion or unauthorized use or disclosure of PHI in violation of this Agreement, or potential loss of confidential data affecting this Agreement. Notification shall be provided to the Agency Procurement Officer at www.state.wv.us/admin/purchase/vrc/agencyli.htm and, unless otherwise directed by the Agency in writing, the Office of Technology at incident@wv.gov or https://apps.wv.gov/ot/ir/Default.aspx.
ii. The Subcontractor shall immediately investigate such Security Incident, Breach, or unauthorized use or disclosure of PHI or confidential data. Within 72 hours of the discovery, the Subcontractor shall notify the Agency Procurement Officer, and, unless otherwise directed by the Agency in writing, the Office of Technology of: (a) Date of discovery; (b) What data elements were involved and the extent of the data involved in the Breach; (c) A description of the unauthorized persons known or reasonably believed to have improperly used or disclosed PHI or confidential data; (d) A description of where the PHI or confidential data is believed to have been improperly transmitted, sent, or utilized; {e) A description of the probable causes of the improper use or disclosure; and (f) Whether any federal or state laws requiring individual notifications of Breaches are triggered.
iii. The Agency will coordinate with Subcontractor to determine additional specific actions that will be required of the Subcontractor for mitigation of the Breach, which may include notification to the individual or other authorities. All associated costs shall be borne by the
Subcontractor. This may include, but not be limited to costs associated with notifying affected individuals.
iv. If the Subcontractor enters into a subcontract relating to the Agreement where the its agent receives PHI as described herein, all such subcontracts or downstream agreements shall contain the same incident notification requirements as contained herein, with reporting directly to the Agency Procurement Officer. Failure to include such requirement in any subcontract or agreement may result in the Agency's termination of the Agreement.
[Use this if the Subcontractor is paying claims] The Subcontractor shall pay all clean claims for Covered Services rendered by its subcontractor to a Member within 30 calendar days of receipt, except to the extent the subcontractor has agreed to later payment in writing. The date of receipt is the date that the Subcontractor received all documentation necessary to pay the claim, as indicated by its date stamp on the claim or other documentation, and date of payment is the date of the check release or other form of payment release to the subcontractor. The Subcontractor shall pay interest in accordance with the Medicaid/WVCHIP Contract requirements for the period in which the clean claim remains unpaid beyond the 30-day period. Interest owed to the subcontractor shall be paid on the same date as the claim.
41. The BMS/CHIP reserves the right to require the replacement of any subcontractor found by the BMS/CHIP to be unacceptable and unable to meet the requirements of the Contract and to object to the selection of a subcontractor.
42. The Contractor must notify the BMS/CHIP of all legal proceedings, actions, and events relating to the Contractor or its subcontractors, affiliates, including parent companies. At a minimum, the following matters must be disclosed:
a. whistleblower or qui tam actions, complaints, or litigation;
b. class-action complaints or lawsuits;
c. legal actions or governmental investigations, alleging fraud or the possibility of fraud;
d. bankruptcy proceedings or petitions where the Contractor, or its subcontractors, affiliates, including parent companies, are named as a debtor;
e. any litigation, mediation, arbitration, between the Contractor and its subcontractor; and
f. criminal actions brought against the Contractor, or its subcontractors, affiliates, including parent companies.
The Contractor must provide written notification within 30 (thirty) calendar days after becoming aware of a matter.
43. Enrollee written materials must be readable at the 6th grade level and easily understood. Materials must be available in alternative formats and in an appropriate manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency. Additionally, all enrollees and potential enrollees must be informed that information is available in alternative formats and how to access those formats. The subcontractor must establish a methodology for identifying the prevalent non-English languages spoken by enrollees and potential enrollees throughout the State, make available written information in each prevalent non-English language, and make oral interpretation services available. These services must be free of charge to each potential enrollee and enrollee. This applies to all non-English languages, not just those that the state identifies as prevalent.
44. The Contractor and subcontractor must comply with the requirements of Section 6505 of the PPACA, entitled “Prohibition on Payments to Institutions or Entities Located Outside of the United States.”
All work performed by the Contractor or a subcontractor under this Contract must be performed exclusively within the United States. No payments shall be made for services or items by the Contractor or a subcontractor to any entity or financial institution outside of the United States.
All information obtained by the Contractor or a subcontractor under this Contract must be stored and maintained within the United States.
45. The Contractor is responsible for any damages, penalties, or disallowances imposed on the State or Contractor arising from any non-compliance or non-performance related to the delivery of the covered services or deliverables under this Contract by the Contractor, its subcontractors or agents.
46. The subcontract must require a written notice of intent to be furnished by the Contractor or its subcontractor in case of the subcontract termination for any reason. A written notice of intent must be given within the following timeframes:
1. 90 days prior to the termination date of a subcontract for systems operations or reporting;
2. 30 days prior to the termination date of a subcontract for administrative services; and
3. 30 days prior to the termination date of any other subcontract. (A written notice of intent is not required in case of a serious breach of a subcontract.)
4. Upon non-renewal or termination of the subcontract, the subcontractor must turn over or provide copies to MCO or BMS/CHIP, or to a designee of BMS/CHIP, all documents, files, and records relating to persons receiving services and to the administration of this contract that BMS/CHIP may request.
47. The Contractor and Subcontractor must provide safeguards that restrict the use or disclosure of information concerning enrollees to purposes directly connected with the administration of this contract. To this end, the Contractor and Subcontractor must establish procedures:
1. To develop and promulgate policies in accordance with Federal and State law establishing who is authorized to receive such information;
2. To safeguard the privacy of any information that identifies a particular enrollee by ensuring that: information from the Contractor or copies of records may be released only to authorized individuals; unauthorized individuals cannot gain access to or alter patient records; and original medical records must be released only in accordance with Federal or State law, court orders, or subpoenas;
3. To address the confidentiality and privacy for minors, subject to applicable Federal and State law; and
4. To abide by all Federal and State laws regarding confidentiality and disclosure for mental health records, medical records, other health information, and any information about an enrollee.
48. All contractors or subcontractors that provide cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation must maintain the confidentiality of medical record information and release the information only in the following manner:
1. All enrollee medical records must be confidential and may not be released without the written consent of the covered persons or responsible party, except as specified below.
i) Written consent is not required for the transmission of medical record information to physicians, other practitioners, or facilities that are providing services to enrollees under a subcontract with the Contractor. This provision also applies to specialty providers who are retained by the Contractor to provide services that are infrequently used or are of an unusual nature. This also allows for transfer of information (written or verbal) to BMS/CHIP staff and to BMS/CHIP subcontractors.
ii) Written consent is not required for the transmission of medical record information to physicians or facilities providing emergency care, or to the Contractor, its staff, contracted providers, or its contractors that are providing cost, quality, or medical appropriateness reviews or coordination of benefits or subrogation.
iii) Written consent is required for the transmission of the medical record information of a former enrollee to any physician not connected with the Contractor, except as set forth in (ii) above.
2. The extent of medical record information to be released in each instance must be based upon tests of medical necessity and a "need to know" basis on the part of the practitioner or a facility requesting the information. Medical records maintained by subcontractors must meet the above requirements.
3. Requirements for access to Subcontractor or Provider records. The Subcontractor or Provider shall provide to WVCHIP: 1. all information required under the MCO’s managed care Contract with WVCHIP, including but not limited to the reporting requirements and other information related to the Subcontractors’ or network providers' performance of its obligations under the Contractor; and 2. any information in its possession sufficient to permit WVCHIP to comply with the federal Balanced Budget Act of 1997 or other federal or state laws, rules, and regulations. If the Subcontractor or network provider place required records in another legal entity's records system and/or platform, the Subcontractor or network provider is responsible for obtaining a copy of these records for use by the above named entities or their representative;
49. The subcontract or subcontractor disclosure forms must provide the definition of ownership per 42 CFR § 455.101. The disclosure forms must request the Subcontractor, Provider, or Sub-subcontractors to disclose information on ownership and control, and information on interlocking relationships per 42 CFR CFR §104 b (3). A Subcontractor that is a business entity, corporation, or a partnership must disclose the name, date of birth (DOB), SSN, and address of each person who is provider’s director, officer, principal, partner, agent, managing employee, or other person with ownership or control interest of five percent (5%) or more in the Subcontractor, Provider, or Sub-Subcontractor.
50. The subcontract or disclosure forms must request the subcontractor to disclose information on ownership and control. A subcontractor that is a business entity, corporation or a partnership must disclose the name, DOB, SSN and address of each person who is a person with ownership and control interest or a partner, officer, director or a managing employee (the Contractor must document whether the control interest is direct or indirect.) The address for corporate entities must include as applicable: primary business address, every business location and P.O. Box address, and tax ID. Disclosure of information on ownership and control must solicit information on interrelationships of persons disclosed per 42 CFR CFR §455.104 (b) and must request tax ID of any Subcontractor, Provider or Provider’s Subcontractor in which the Subcontractor (if entity) has a five percent (5%) or more interest. Disclosure of information on ownership and control must request the name of each entity in which the provider’s persons with ownership and control interest have an ownership or control interest. The Subcontractor must agree to keep information current at all times by informing the Contractor in writing within thirty-five (35) calendar days of any ownership and control changes to the information contained in its application.
51. The subcontract or disclosure forms must request the tax ID for those subcontractors in which the Contractor subcontractor (if entity) has a 5 percent or more interest.
52. The subcontractor or disclosure forms must request information on interrelationship of persons. Specifically, whether the person (individual or corporation) with an ownership or control interest in any subcontractor in which the Contractor has a 5 percent or more interest is related to another person with ownership or control interest in Contractor as a spouse, parent, child, or sibling
53. Subcontractor must certify that the subcontractor and its owners, persons with control interest, managing employees, partners, directors, and officers have not been excluded, suspended, debarred, revoked or any other synonymous action from participation in any program under Title XVIII (Medicare), Title XIX (Medicaid/CHIP), or under the provisions of Executive Order 12549, relating to federal agreement. Subcontractor must certify that persons listed above have also not been excluded, suspended, debarred, revoked or any other synonymous action from participation in any other state or
federal health-care program. Subcontractor must verify certified information through: GAS-EPLS, HHS-OIG LEIE, State Exclusion List.
54. Subcontractor must certify that the subcontractor and its owners, persons with control interest, managing employees, partners, directors, and officers have not been excluded, suspended, debarred, revoked or any other synonymous action from participation in any program under Title XVIII (Medicare), Title XIX (Medicaid/CHIP), or under the provisions of Executive Order 12549, relating to federal agreement. Subcontractor must certify that persons listed above have also not been excluded, suspended, debarred, revoked, or any other synonymous action from participation in any other state or federal health-care program. Subcontractor must verify certified information through: GAS-EPLS, HHS-OIG LEIE, and State Exclusion List.
55. The Subcontractor may notify the Contractor immediately at the time it receives notice that any action is being taken against a subcontractor or any person above as defined under the provisions of Section 1128(A) or (B) of the Social Security Act (42 USC §1320a-7), which could result in exclusion from the Medicaid/CHIP program.
56. The Subcontractor agrees to fully comply at all times with the requirements of 45 CFR Part 76, relating to eligibility for federal agreements and grants.
57. The subcontract or subcontract disclosure forms must request the subcontractor, its owners, persons with control interest, provider agents, officers, partners and managing employees to disclose information on criminal convictions related to Medicare, Medicaid/CHIP, or Title XX programs at the time they apply or renew their applications for Medicaid/CHIP participation or at any time on request. In addition, the subcontractor may notify the Contractor immediately at the time it receives notice of such conviction.
58. The subcontract must specify that operational information, including correspondence, documentation of ongoing or outstanding issues, operations support documentation, and operational information regarding Subcontractors as part of Contractor’s Transition.
59. The subcontract must stipulate that the Subcontractor must satisfy all Readiness Review requirements prior to the Subcontractor(s) operational start date.
60. The subcontract must prohibit billing enrollees any amount greater than would be owed if Contractor provided the services directly, if applicable. Enrollees must be held harmless for the costs of all Medicaid/CHIP-covered services provided except for applicable cost-sharing obligations. If applicable, Subcontractor must inform enrollee members in writing of the costs for non-covered services prior to rendering such services. The MCO’s enrollee/members may not be held liable for the Subcontractor’s debts in the event of the Subcontractor’s insolvency.
61. The subcontract must require reducing payments to the network providers by the amount of the member’s copay, regardless of whether the provider successfully collects the copay. The Subcontractor or providers may not routinely waive required co-pays.
62. The subcontract must provide that the Subcontractor or its providers may not charge co-pays to the following Contractor members:
63. The Contractor shall enter into a Subcontract agreement to fulfill the requirements of this Contract. Subcontracts must comply with the requirements of 42 CFR CFR §434.6 and 42 CFR CFR §438.230. If applicable, the Subcontractor shall full comply with Medicaid members grievance, appeal, and fair hearing procedures and timeframes. The subcontract must provide that the subcontractor or its providers may not charge co-pays to the following Contractor services:
The subcontract must require compliance with the enrollee grievance, appeal, and fair hearing procedures and timeframes
64. The Subcontractor shall have written policies and procedures for maintaining the confidentiality of data, including medical records/enrollee information and adolescent/STD appointment records. The policies must be in accordance with the privacy requirements in 45 CFR parts 160 and 164, upon their effective dates, to the extent applicable. All enrollee information, medical records, data and data elements collected, maintained or used in the administration of this contract must be protected from unauthorized disclosure.
65. Subcontractors must comply with all applicable Federal and State laws, including the HIPAA Privacy and Security Rule governing the use and disclosure of protected health information.
66. Contractor must explain the definition of “Convicted” in the disclosure form per 42 CFR 1001.2, which includes all convictions, deferred adjudications, and all types of pretrial diversion programs.
67. The Subcontract must comply with the SMDL 06-024. If the entity receives annual Medicaid/CHIP payments of at least $5 million (cumulative, from all sources), requiring the Subcontractor: 1. Establish written policies for all employees, managers, officers, contractors, subcontractors, and agents of the network provider. The policies must provide detailed information about the False Claims Act, administrative remedies for false claims and statements, any state laws about civil or criminal penalties for false claims, and whistleblower protections under such laws, as described in Section 1902(a)(68)(A). 2. Include as part of such written policies detailed provisions regarding the network provider’s policies and procedures for detecting and preventing Fraud, Waste, and Abuse. 3. Include in any employee handbook a specific discussion of the laws described in Section 1902(a)(68)(A), the rights of employees to be protected as whistleblowers, and the provider’s policies and procedures for detecting and preventing Fraud, Waste, and Abuse.
68. The Subcontract must follow marketing requirements.
69. The Subcontract must specify procedures and criteria for terminating the contract, including a requirement that the contractor promptly supply all information necessary for the reimbursement of any outstanding Medicaid/CHIP claims.
70. The subcontract covering behavioral services must be rendered by providers within the scope of their license and in accordance with all state and federal requirements.
71. The subcontract must require that a subcontractor has in place, and follows, written policies and procedures for processing requests for initial and continuing authorizations of services
72. The subcontract must maintain a Provider Services Department and operate a toll-free provider phone line for at least eight (8) hours a day during regular business hours with the following service levels:
-Eighty-three percent (83%) of calls are answered live within thirty (30) seconds during operating hours. Time measured begins when the provider is placed in the call queue to wait to speak to a Provider Services representative
-The call abandonment rate does not exceed five percent (5%) of total calls for the reporting period.
73. Reimbursement terms: The Contract must provide a complete description of the payment method or payment amounts applicable to a provider. The MCO provider Contract or provider manual must explain to providers how to submit a clean claim including a complete listing of all required information, including claims coding and processing guidelines for the applicable provider type. The MCO provider must understand and agree that WVCHIP is not liable or responsible for payment for covered services rendered pursuant to the MCO provider contract.
74. If applicable, Subcontractors or Providers attest to the following certification for claims for WVCHIP goods and services. The certification includes the following information: All statements are true, accurate, and complete; no material fact has been omitted; all services will be Medically Necessary to the health of the specific patient; and understanding that payment will be from Federal and State funds and that any falsification or concealment of a material fact may be prosecuted under Federal and State law.
75. Subcontractors who contract directly with Providers in accordance with 42 CFR §455.105. MCO provider contracts must include language specifying that the contracted provider is required to disclose the following information related to business transactions within thirty-five (35) calendar days of request of the Secretary of DHHS or WVCHIP: full and complete information about (1) the ownership of any Subcontractor with whom the provider has had business transactions totaling more than $25,000 during the previous 12-month period and (2) any significant business transactions between the provider and any wholly owned supplier, or between the provider and any Subcontractor, during the previous five (five) years.
76. Requirement for Providers to comply with 42 CFR §457.1224. The Contract must prohibit providers from engaging in direct marketing to enrollee/members that is designed to increase enrollment in a particular MCO. The prohibition should must not constrain providers from engaging in permissible marketing activities consistent with broad outreach objectives and application assistance.
EXHIBIT E-30
WISCONSIN BADGERCARE PLUS PARTICIPATION ATTACHMENT AND STATE-SPECIFIC REQUIREMENTS
This Exhibit is attached to and incorporated into the Agreement and is applicable solely to Vendor Services provided to or for the administration of the BadgerCare Plus programs in the state of Wisconsin. To the extent any provisions herein conflict with the provisions set forth in the Agreement, the provisions in this Exhibit shall control for those Vendor Services provided to Covered Individuals enrolled in the Wisconsin BadgerCare Plus programs.
U.S. must clearly indicate Wisconsin law as jurisdiction for any breach of contract and ensure compliance with state and federal laws allowing for such contracts.
necessary and covered BadgerCare Plus and/or Medicaid SSI benefits (e.g., COB recovery procedures that delay or prevent care).
The standard release form signed by the member at the time of services does not relieve the HMO and its providers and subcontractors from the prohibition against billing a BadgerCare Plus or Medicaid SSI member in the absence of a knowing assumption of liability for a non-covered service. The form or other type of acknowledgment relevant to BadgerCare Plus or Medicaid SSI member liability must specifically state the admissions, services, or procedures that are not covered by BadgerCare Plus or Medicaid SSI.
before they take effect. This review requirement applies to changes that affect the amount, duration, scope, location, or quality of services.
The HMO must submit new subcontracts to the Department for review and approval before they take effect. If the Department does not respond to the request for review within 15 business days of submission, the HMO must contact the HMO Unit Supervisor in the Bureau of Quality and Oversight. A response will be prepared within five business days of this contact.
The Department may approve, approve with modification, or deny subcontracts under this Contract at its sole discretion. The Department.