AMD RE FQHC AMENDMENT WITH CARE1ST.PDF

AMENDMENT
TO THE CARE1ST HEALTH PLAN ARIZONA, INC.
PROVIDER SERVICES AGREEMENT
This Amendment is effective the 1st day of April, 2015 and modifies the CARE1st HEALTH
PLAN ARIZONA, INC. PROVIDER SERVICES AGREEMENT (hereinafter “Agreement”) by
and between CARE1st HEALTH PLAN ARIZONA, INC., an Arizona Corporation, (hereinafter
“Plan”), and MARICOPA COUNTY BY AND THROUGH ITS DEPARTMENT OF PUBLIC
HEALTH, HEALTHCARE FOR THE HOMELESS (hereafter “PROVIDER”).
Whereas, Plan and PROVIDER entered into an Agreement effective September 1, 2010; and
Whereas, Plan and PROVIDER agree to amend the Agreement as follows:
 ARTICLE II PLAN RESPONSIBILITIES section 2.3 is replaced with the following:
2.3 Plan shall verify Plan Member eligibility and the scope of Covered Health Care
Services the Plan Member is eligible to receive from PROVIDER upon request from
PROVIDER.
 ARTICLE III PROVIDER RESPONSIBILITIES section 3.9 is replaced with the following:
3.9 PROVIDER shall comply with all Plan and AHCCCS performance standards including
the AHCCCS Minimum Subcontract Provisions, appointment, availability, and wait
time standards, and EPSDT requirements and standards, policies and procedures as
described in the Provider Services Manual, as well as with the provisions of the Plan
Contract(s), and all other applicable state and federal laws and regulations relating to
the delivery of Covered Health Care Services.
 ARTICLE III PROVIDER RESPONSIBILITIES section 3.24 is added:
3.24 PROVIDER at no time shall engage in the practice of solicitation of Plan Members
without Plan’s prior written consent. For purposes of this Agreement, solicitation shall
mean any action by PROVIDER to encourage or persuade a Plan Member to
discontinue his/her relationship with Plan. Upon member request, Solicitation of
Member shall not prohibit PROVIDER from notifying Plan Members of PROVIDER’s
participation status with other AHCCCS contractors.
 ARTICLE V UTILIZATION AND QUALITY MANAGEMENT PROGRAMS section 5.4
is added:
5.4 Nothing in this Agreement, including PROVIDER’s participation in the Utilization
Management and Quality Management programs shall be construed to interfere with or
in any way affect PROVIDER’s obligation to exercise independent medical judgment in
rendering health care services to Plan Members, nor shall this Agreement change or alter
any clinical relationship which exists or may come to exist between PROVIDER and a
Plan Member. PROVIDER shall have the same duties, liabilities and responsibilities to
Plan Members as exist generally between a patient and medical provider. PROVIDER
shall exercise best medical judgment in the treatment of Plan Members and discussing
medical treatment options with Plan Members. Payment determinations by Plan shall
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not be construed as a directive from Plan that medically necessary treatment should be
withheld. At no time shall any Plan or PROVIDER be financially and/or otherwise
incented to make medical decisions that may deny, limit or discontinue any medically
necessary services to a Plan Member.
 ARTICLE VI REGULATORY COMPLIANCE section 6.2 is replaced with the following:
6.2 Plan is also subject to Plan Contract(s) between the Plan and AHCCCS, as amended
from time to time. Any provisions required to be in this Agreement by these Plan
Contracts, as amended, shall bind both parties whether or not provided in this
Agreement. This includes compliance with all AHCCCS provider manuals and policy
guidelines, including the AHCCCS Minimum Subcontract Provisions found on the
AHCCCS public website in this location:
http://www.azahcccs.gov/commercial/MinimumSubcontractProvisions.aspx, and any
amendments thereto, all of which are incorporated by reference into this Agreement.
 ARTICLE VI REGULATORY COMPLIANCE section 6.5 is replaced with the following:
6.5 Plan has established an Anti-Fraud Plan to organize and implement an anti-fraud
strategy to identify and reduce costs to Plan, its Plan Members, providers and others
caused by fraudulent activities, and to protect consumers through the timely detection,
investigation and prosecution of suspected fraud. PROVIDER agrees that it has
received, read and understood this Anti-Fraud Plan, shall abide by the requirements of
the same (or shall maintain its own anti-fraud/compliance program that meets or
exceeds the standards of Plan’s Anti-Fraud Plan) and make the same available to its
employees, subcontractors and agents involved in providing services under this
Agreement. The Anti-Fraud Plan is accessible via the Plan’s website. PROVIDER
further agrees to abide by the compliance policies and applicable standards of conduct
in the Anti-Fraud Plan established by Plan, to the extent that they directly or indirectly
bear upon the subject matter of this Agreement.
 ARTICLE VI REGULATORY COMPLIANCE sections 6.8 through 6.11 are replaced with
the following:
6.8 PROVIDER shall preserve and make available, at no cost, all records for a period of
five years from the date of final payment under this Agreement unless a longer period
of time is required by law. For retention of patient medical records, PROVIDER shall
ensure compliance with A.R.S. §12-2297 which provides, in part, that a health care
provider shall retain patient medical records according to the following:
1. If the Plan Member is an adult, PROVIDER shall retain the patient medical
records for at least six (6) years after the last date the adult patient received
medical or health care services from that provider.
2. If the Plan Member is under 18 years of age, PROVIDER shall retain the patient
medical records either for at least three (3) years after the child's eighteenth
birthday or for at least six (6) years after the last date the child received medical
or health care services from PROVIDER, whichever date occurs later.
6.9 PROVIDER shall maintain records relating to covered services and expenditures
including reports to AHCCCS and documentation used in the preparation of reports to
AHCCCS. PROVIDER shall comply with all specifications for record keeping
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established by AHCCCS. All books and records shall be maintained to the extent and
in such detail as required by AHCCCS Rules and policies. If this Agreement is
completely or partially terminated, the records relating to the work terminated shall be
preserved and made available, at no cost, for a period of five years from the date of any
such termination. Records which relate to grievances, disputes, litigation or the
settlement of claims arising out of the performance of this contract, or costs and
expenses of this contract to which exception has been taken by AHCCCS, shall be
retained by the PROVIDER for a period of five (5) years after the date of final
disposition or resolution thereof unless a longer period of time is required by law.
6.10 PROVIDER agrees to permit access to AHCCCS or Plan, or their authorized
representatives, at all reasonable times upon demand, to inspect all facilities maintained
or utilized by PROVIDER in the provision of Covered Health Care Services under this
Agreement.
6.11 PROVIDER agrees to maintain, provide to Plan, and, upon request, make available to
AHCCCS, copies of all subcontracts for the provision of Covered Health Care Services
and to ensure that all such subcontracts are in writing, comply with applicable laws,
regulations, AHCCCS Policies the terms of this Agreement. PROVIDER further
agrees to notify Plan in the event any agreement with a subcontractor for the provision
of Covered Health Care Services is amended or terminated. Notice is considered given
when properly addressed and deposited in the United States Postal Service as first-class
registered mail, postage attached.
 Add the following to section 6.14 of ARTICLE VI REGULATORY COMPLIANCE:
6.14 If PROVIDER discovers, or is made aware, that an incident of suspected fraud or abuse
has occurred, PROVIDER must report the incident to AHCCCS, Office of the
Inspector General (AHCCCS-OIG) immediately within one business day and to the
Plan.
 ARTICLE X LIABILITY, INDEMNITY AND INSURANCE section 10.3 is replaced with
the following:
10.3 PROVIDER, at its sole expense, agrees to maintain professional liability insurance of
not less than One Million ($1,000,000) per claim and Three Million annual aggregate
($3,000,000), maintain additional insurance requirements, i.e. Commercial General
Liability, Business Automobile Liability and Worker’s Compensation and Employers’
Liability, defined by AHCCCS and such other available insurance as shall be
necessary to insure PROVIDER and its employees against any and all damages arising
from its duties and obligations under this Agreement. PROVIDER shall notify Plan at
least thirty (30) days prior to the termination, cancellation or lapse of any such policy.
PROVIDER shall also provide Workers' Compensation benefits for its employees as
required by Arizona law. PROVIDER is responsible for all PROVIDER tax
obligations including but not limited to payroll withholding. AHCCCS shall have no
responsibility or liability for any such taxes or insurance coverage.
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 ARTICLE XV GENERAL PROVISIONS section 15.1 is replaced with the following:
15.1 Assignment This Agreement may not be assigned by PROVIDER, nor may the duties
hereunder be delegated, without prior written approval. Plan may assign, delegate or
transfer this Agreement in whole or in part to any affiliate existing now or in the future,
or to any entity which succeeds to the applicable portion of its business through sale,
merger, or other transaction, provided that such entity assumes the obligations of Plan
hereunder.
 ATTACHMENT A PROVIDER SERVICES AND COMPENSATION is replaced in its
entirety with the enclosed ATTACHMENT A PROVIDER SERVICES AND
COMPENSATION.
 ATTACHMENT B AHCCCS Minimum Subcontract Provisions and all references to
ATTACHMENT B AHCCCS Minimum Subcontract Provisions are removed from the
Agreement.
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INTEGRATION; CONFLICTS
This Amendment represents the complete agreement between the parties regarding the subject
matter hereof, and no other changes or modifications of the Agreement are intended nor shall any
such other changes or modifications exist. In the event of a conflict between the terms of the
Agreement and this Amendment, the terms of this Amendment shall control.
IN WITNESS WHEREOF, CARE1st HEALTH PLAN ARIZONA, INC. executes this
Amendment as of the date set forth below to be effective on the effective date specified above.
Care1st Health Plan Arizona, Inc.
Scott Cummings
Chief Administrative Officer
Date: February 23, 2015
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ATTACHMENT A
PROVIDER SERVICES AND COMPENSATION
PROVIDER is responsible for providing all necessary Covered Health Care Services (prior authorized, if
required) to referred Plan Members, consistent with the standards of PROVIDER’s specialty, dependent
on the level of training the Provider has received, the limitations of scope of practice and consistent with
State and Federal rules and regulations.
Plan’s Fee Schedule may be revised with fifteen (15) days written notification to PROVIDER by Plan. Plan
shall implement changes to Plan’s Fee Schedule within sixty (60) days of receipt of AHCCCS confirmation
of rate changes. PROVIDER shall be reimbursed within sixty (60) days of the Plan’s receipt of a clean claim.
FQHC Payment. FQHC payment shall be effective as determined by AHCCCS and is dependent upon
successful completion of the required AHCCCS registration process. Per AHCCCS guidelines, the FQHC
payment shall be applied only when both the effective date and registration conditions are met. Claims for
dates of service prior to the AHCCCS determined effective date and/or prior to successful completion of the
registration process shall be processed under the prior Fee-For-Service methodology and not the PPS
methodology.
PROVIDER shall follow the billing guidelines outlined by AHCCCS and Plan shall reimburse PROVIDER
the lesser of the unique FQHC PPS rate established by AHCCCS for PROVIDER for applicable Covered
Health Care Services provided by PROVIDER to Plan Members or PROVIDER’s charges, less any
applicable Co-Payments, Deductibles and Coinsurance. The FQHC PPS rate is an all inclusive visit rate that
shall be paid per visit and shall serve as the full reimbursement for the visit and other related services. At no
time shall Plan pay an amount that exceeds PROVIDER’s billed charges. Covered Health Care Services not
qualifying for payment under the FQHC PPS rate shall be reimbursed according to the Fee-For-Service
Payment section below.
Fee-For-Service Payment. Payment for Covered Health Care Services provided by PROVIDER to Plan
Members that do not qualify for FQHC Payment shall be based on the lesser of the Plan’s Fee Schedule
defined in the table below or PROVIDER’s charges, less any applicable Co-Payments, Deductibles and
Coinsurance. Services with no rates shall be reimbursed according to Plan’s criteria until rates are
established. At no time shall Plan pay an amount that exceeds PROVIDER’s billed charges.
The following services are excluded from Plan’s Fee Schedule and paid at Plan’s defined rates less Co-
Payments, Deductibles and Coinsurance: in office lab testing and radiology, immunizations, obstetrical
pre/post/delivery services, certain Covered Services coded with HCPCS codes and injectable drugs.
Reimbursement Schedule Care1st Acute Care, Kids Care &
DDD Reimbursement
Primary Care Physicians (Peds, 100% of the AHCCCS Fee For
IM, GP, FP) Service rates prevailing as of the
date of service
Mid-level Practitioners (e.g. 85% of the AHCCCS Fee For
CRNAs, CNMs, PhDs, NPs, Service rates prevailing as of the
PAs, etc.) date of service
Vaccines For Children (VFC) Program. Plan will not reimburse PROVIDER for the costs of
immunizations available free-of-charge to PROVIDER through the VFC program. Plan will reimburse
PROVIDER for the administration of these vaccines according to Plan’s defined rates.
Care1st A.1 of A.1
Revised 021015

C-86-11-009-3-01 ATTACHED TO AND A PART OF
Amendment
Care1st Health Plan Arizona, Inc.
IN WITNESS WHEREOF, the parties agree to enter into this Contract:
FOR AND ON BEHALF OF
MARICOPA COUNTY
By
Chairman, Board of Supervisors
Date
ATTEST:
Clerk of the Board
Date
APPROVED AS TO FORM:
Attorney for Maricopa County
Date