YH08-0073-MARICOPA COUNTY TPA-PARTIALLY EXECUTED.PDF

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
INTERGOVERNMENTAL AGREEMENT AMENDMENT
1AMENDMENT 2. CONTRACT NUMBER: 3. EFFECTIVE DATE OF AMENDMENT: 4. PROGRAM:
NUMBER: 8 YHO8-0073 July 1, 2016 DFSM
C-26-08-011-0-04
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, 2017.
B. Pursuant to Paragraph 5.7, Administrative Services: Change rates for SFY2017 (July 1, 2016 — June 30, 2017) to
the rates as shown in Attachment A.
. 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 10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
CORRECTIONAL HEALTH SERVICES
SIGNATURE OF AUTHORIZED INDIVIDUAL: SIGNATURE:
TYPED NAME: TYPED NAME:
CLINT L. HICKMAN MkElli GGAN HA
TITLE: TITLE:
CHAIRMAN, COUNTY BOARD OF SUPERVISORS ACTING CHIEF PROCUREMENT OFFICER
DATE: DATE:
May 26,2016
11. IN ACCORDANCE WITH STATE STATUTES, COUNTY RULES, 12. IN ACCORDANCE WITH § A.R.S. 11-952, THIS AMENDMENT IS IN PROPER
AND BYLAWS, THIS AGREEMENT HAS BEEN REVIEWED BY THE FORM AND IS WITHIN THE POWER AND AUTHORITY GRANTED TO THE
UNDERSIGNED WHO 1-LAS DETERMINED THAT THIS ADMINISTRATION UNDER § A.R.S 36-2903 ET SEQ. AND §36-2932 ET SEQ.
AGREEMENT IS IN APPROPRIATE FORM AND IS WITHIN THE
POWER AND AUTHORITY GRANTED TO THE COUNTY.
0- II
DATED THIS DAY OF , 2016 DATED T. "1" DAY 0 2016
- . k
BY A1°.°f iv / Alligi
DEPUTY COUNTY ATTORNEY L -GAL COUNS% OR THE ADMINISTRATION
1

YHO8-0073
AHCCCS AMENDMENT #8
ATTACHMENT A
Administrative Annual Cost Estimates for
Maricopa County Corrections 100% State IGA SFY17
Claims Electronic Paper Total Fund
71% 29% 100%
Estimated total number of claims:
Physician & Emergency Transport/Hospital 18,400 7,600 26,000
DFSM Cost per Claim 2 $ 0.34 $ 0.41
OIG Cost per Claim 2 $ 0.05 $ 0.05
ISD Cost per Claim 2 $ 1.87 $ 1.87
Concurrent Review Average Cost
Estimated cost per case 3 $ 101.06
Estimated number of HSAG reviews 4 5
Claims Processing costs:
DFSM $6,329.48 $3,093.51 $9,423.00
OIG $978.11 $404.00 $1,382.11
ISD $34,474.54 $14,239.48 $48,714.02
Total Claims Processing Costs $41,782.13 $17,737.00 $59,519.13
Direct DFSM Labor for MDOC 100% Claims Procest 5 102,559.72
Direct ISD Labor for MDOC 100% Claims Processin 6 $14,000.00
Concurrent Review Estimated costs:
Cost for 5 reviews $505.31
Administrative Costs (see detail)
DBF Paper Processing Personnel costs 7 $11,619.53
Postage @ $.0680/claim 8 $1,768.00
Data Center Charges @ $.2213/claim 9 $5,753.80
Indirect at 10% $1,161.95
Total DBF Administrative Costs $20,303.29
Estimated Total Annual Costs for Program $196,887.44
Cost per Claim 10 $7.55
Actual number of claims may be higher. Number includes, original, recoupment and adjustment claims.
2 Cost based on actual SFY15 expenditures and actual number of claims processed
3 Average rate per contract. Actual costs will be a strict pass-through based on price negotiated
on new contract.
4 Actual number may be higher or lower depending on MDOC 100% State requirements.
5 Based on estimates of DFSM staff time required to process the claims.
6 Estimate based on 80 hours at a rate of $175 per hour. Will only be billed for actual hours incurred.
7 Based on estimates of DBF staff time required to monitor funding activity and process payments.
8 Postage based on average cost per claim times number of claims.
9 Data Center charges calculated based on average SFY15 costs
16 Cost per claim does not include a cost for concurrent reviews