AHCCCS - IGA PAYMENT SERVICES - SIGNED - C-26-08-011-0-11.PDF

C C S
Arizona Health Care Cost Containment System
INTERGOVERNMENTAL AGREEMENT
AMENDMENT
1. Amendment 2. CONTRACT NUMBER: 3. EFFECTIVE DATE OF AMENDMENT: 4. PROGRAM:
11 YHO8-0073 July 1, 2019 DFSM
C-26-08-011-0-11
5. CONTRACTOR/PROVIDER NAME AND ADDRESS:
Maricopa County on behalf of
Correctional Health Services
234 N. Central, Suite 5000
Phoenix, AZ 85004
6. PURPOSE: To revise rates and extend the term of the agreement for an additional (12) twelve months.
7. The above referenced contract is hereby amended as stated below:
A. Pursuant to Paragraph 6.1, Term of Agreement, the contract term is hereby extended for an additional twelve months
through June 30, 2020.
B. Pursuant to Paragraph 5.7, Administrative Services: Change rates for SFY2020 (July 1, 2019— June 30, 2020) to the
rates as shown in Attachment A.
NOTE: Please return scanned copy to: Melannie Rustein, Sr Procurement Specialist at: Melannie.Rustein@azahcccs.gov
8. Except as provided for herein, all terms and conditions of the original contract not heretofore changed and/or amended remain
unchanged and in full effect.
In witness whereof the parties hereto sign their names in agreement.
9. Maricopa County on behalf of Correctional Health 10. Arizona Health Care Cost Containment System
Services
SIGNATURE OF AUTHORIZED INDIVIDUAL: SIGNATURE:
TYPED NAME: TYPED NAME:
Alice McLain, MBA
TITLE: TITLE:
Chairman, County Board of Supervisors Procurement Manager
DATE: DATE:
/47/ 7 ,1
11. In accordance with state statutes, county rules, and bylaws, 12. In accordance with § A.R.S. 11-952, this amendment is in proper form and
this agreement has been reviewed by the undersigned who is within the power and authority granted to the administration under §
has determined that this agreement is in appropriate form and A.R.S. 36-2903 et seq. and §36-2932 et seq.
is within the power and authority granted to the county.
er4s, daYof_
ill
Dated this I 1° P. day of ,2019 Dated this jly 2019
B(C -'2"). L ecirs
y aunty Attorney Legal counsel forjit a ininistr tion

AHCCCS YHO8-0073
Administrative Annual Cost Estimates for Amendment 11
Maricopa County Corrections 100% State IGA SFY20 Attachment A
Claims Electronic Paper Total Fund
91% 9% 100%
Estimated total number of claims:
Physician & Emergency Transport/Hospital 22,885 2,377 25,262
DFSM Cost per Claim 2$ 0.62 0.71
OIG Provider Enrollment Cost per Claim 2$ 0.14 0.14
ISD Cost per Claim 2$ 1.51 1.51
Concurrent Review Average Cost
Estimated cost per case 3 $ 121.86
Estimated number of HSAG reviews 4 5
Claims Processing costs:
DFSM $14,158.25 $1,699.41 $15,857.66
OIG Provider Enrollment $3,144.11 $326.57 $3,470.68
ISD $34,637.74 $3,597.72 $38,235.46
State Accounting System Charges @ $0.1723/claim $3,943.48 $409.60 $4,353.08
Total Claims Processing Costs $55,883.58 $6,033.30 $61,916.88
Direct DFSM Labor for MDOC 100% State Claims Processing 5 98,458.15
Direct ISD Labor for MDOC 100% State Claims Processing 6 $14,000.00
Concurrent Review Estimated costs:
Cost for 5 reviews $609.30
Administrative Costs (see detail)
DBF Paper Processing Personnel costs 7 $ 9,235.24
Postage @ $.0410/claim $1,036.04
Data Center Charges @ $.7366/claim 9 $18,608.50
OOD @ $.2819/claim $7,122.37
OALS @ $.0782/claim $1,975.42
HRD @ $.0239/claim $603.41
TIBCO @ $.2866/claim $7,239.04
Indirect at 10% $4,582.00
Total Administrative Costs $ 50,402.02
DMS Eligibility Costs
Application Processing Costs - DMS 10 $0.00
Estimated Total Annual Costs for Program $225,386.34
Cost per Claim 11 $8.90
Actual number of claims may be higher. Nurrber includes, original, recoupment and adjustment claims.
2 Cost based on actual SFY18 expenditures and actual nunber of claims processed
Average rate per contract. Actual costs w ill be a strict pass-through based on price negotiated on contract.
Actual number may be higher or low er depending on Maricopa Co 100% State Inmate program requirements.
5 Based on estimates of DFSM staff time required to process the claims.
Estimate based on 80 hours at a rate of $175 per hour. WII only be billed for actual hours incurred.
1 Based on estimates of DBF staff time required to monitor funding activity and process payments.
Postage based on average cost per claim times number of claims.
9 Data Center charges calculated based on average SFY18 costs
DMS Eligibility charges calculated at $100/deternination. Estimated 0 annual applications/determinations.
11 Cost per claim does not include a cost for concurrent review s