AHCCCS TPA AMEND#5 TO EXTEND.PDF

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION
DIVISION OF BUSINESS AND FINANCE
INTERGOVERNMENTAL AGREEMENT AMENDMENT
LAMENDMENT 2. CONTRACT NUMBER: 3. EFFECTIVE DATE OF AMENDMENT: 4. PROGRAM:
NUMBER: 5 YHO8-0073 July 1,2013 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, 2014.
B. Pursuant to Paragraph 5.7, Administrative Services: Change rates for FY2014 (July 1, 2013 — June 30, 2014) to the
rates as shown in Attachment A.
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 10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
CORRECTIONAL HEALTH SERVICES
SIGNATURE OF AUTHORIZED INDIVIDUAL: SIGNATURE:
jittidt
TYPED NAME: TYPED NAME:
ANDREW KUNASEK "' MEGGAN HALEY
TITLE: TITLE:
CHAIRMAN, COUNTY BOARD OF SUPERVISORS PROCUREMENT AND CONTRACTS MANAGER
DATE: DATE:
JULY 3, 2013
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 HAS 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 oispc;‘,
POWER AND AUTHORITY GRANTED TO THE COUNTY.
DATED THIS 1 DAY OF i It 1 .2013
DATED THIS _ DAY OF .2013
..4i. _.2.01 ...,4
BY L GAL COUNS pie R THE ADMINISTRATION
DEPUTY COUNTY ATTORNEY
1

YHO8-0073
AHCCCS AMENDMENT #5
ATTACHMENT A
Administrative Annual Cost Estimates for
Maricopa County Department of Corrections 100% State IGA SFY14
Claims Electronic Paper Total Fund
81% 19% 100%
Estimated total number of claims:
Physician & Emergency Transport/Hospital 19,675 4,550 24,225
DFSM Cost per Claim 0.37 0.60
OIG Cost per Claim 0.10 0.10
ISO Cost per Claim 2.13 2.13
Concurrent Review Average Cost
Estimated cost per case 2 $ 96.25
Estimated number of HSAG reviews 3 5
Claims Processing costs:
DFSM $7,284.98 $2,709.20 $9,994.18
GIG $1,972.03 $456.05 $2,428.08
ISO $41,822.46 $9,693.91 $51,516.37
Total Claims Processing Costs $51,079.48 $12,859.16 $63,938.64
Direct DFSM Labor for MDOC 100% Claims Processing 88,779.00
Direct ISO Labor for MDOC 100% Claims Processing $14,000.00
Concurrent Review Estimated costs:
Cost for 5 reviews $481.25
Administrative Costs (see detail)
DBF Paper Processing Personnel costs $10,001.00
Postage @ $.09/claim 4 $2,180.25
Data Center Charges @ $.31/claim 5 $7,509.75
Indirect at 10% $1,000.10
Total DBF Administrative Costs $20,691.10
Estimated Total Annual Costs for Program $187,889.99
Cost per Claim $7.74
Actual number of claims may be higher. Number includes original, recoupment and adjustment claims.
2 Average rate per contract. Actual costs will be a strict pass-through based on price negotiated
on new contract.
Actual number may be higher or lower depending on MDOC 100% State requirements.
Postage based on average cost per claim times number of claims.
5 Data Center charges calculated based on average SFY11 costs
6 Cost per claim does not include a cost for concurrent reviews