AHCCCS - PAYMENT SERVICES AMENDMENT 12 - SIGNED.PDF

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SAHCCCS

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* Arizona Health Care Cost Containment System

INTERGOVERNMENTAL AGREEMENT

AMENDMENT
1. Amendment | 2. CONTRACTNUMBER: | 3. EFFECTIVE DATE OF AMENDMENT: 4. PROGRAM:
12 YHO8-0073 July 1, 2020 DFSM
C-26-08-011-0-12

5, CONTRACTOR/PROVIDER NAME AND ADDRESS:

Maricopa County
c/o 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 and to
revise the terms of this agreement.

1. 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, 2021.

B. Pursuant to Paragraph 5.7, Administrative Services: Change rates for SFY2021 (July 1, 2020 — June 30,
2021) to the rates as shown in Attachment A.

2. Pursuant to the Preamble of Agreement, this agreement is for the processing of Medicaid claims for
inpatient services, defined as an admission to a medical institution, as defined in 42 C.F.R. § 435.1010,
equal to or greater than 24 hours in a non-locked ward.

A. Add Section 13 Department Compliance with CMS Regulations.

13.1 The Department shall not impose requirements upon a medical institution that are
inconsistent with federal regulation and guidance issued by the Centers for Medicare
and Medicaid Services, including State Health Official Letter 16-007 and Survey &
Certification Letter 16-21-ALL REV.

B. Add Section 14 Consequences of Disallowance by CMS.

14.1 Inthe event the federal government disallows a claim by AHCCCS for federal
financial participation based on the Department's failure to comply with this Agreement,
the Department shall, within 30 days of written demand from AHCCCS, make a payment
to AHCCCS equal to the amount due to CMS as the result of the disallowance, including
any interest incurred as a result of an appeal of the disallowance. AHCCCS will consult
with the Department regarding an administrative appeal of a disallowance; however,
AHCCCS has the sole discretion on the decision whether to pursue an administrative
appeal.

3. Update Section 8.1 with: This Amendment is subject to cancellation pursuant to A.R.S. 38-511.

NOTE: Please return a scanned copy to: Melannie Rustein; Sr. Procurement Specialist at: Melannie.Rustein@azahcccs.gov

unchanged and in full effect.

7. Except as provided for herein, all terms and conditions of the original contract not heretofore changed and/or amended remain

In witness whereof the parties hereto sign their names in agreement.

8. Maricopa County

9. Arizona Health Care Cost Containment System

‘SIGNATURE OF AUTHORIZED INDIVIDUAL: SIGNATURE:
Meggan LaPorte (Oct 23, 2020 14:37 PDT)
TYPED NAME: TYPED NAME:
Clint Hickman Meggan LaPorte, CPPO, MSW
TITLE: TITLE:
Chairman, County Board of Supervisors Chief Procurement Officer
DATE: DATE:

Oct 23, 2020

11. In accordance with state statutes, county rules, and bylaws,
this agreement has been reviewed by the undersigned who

has determined thaf-this agreementis in appropriate form
and V4 fower and authority granted to the county.
Date: ra w2) h, éL20 20

12. Inaccordance with § A.R.S. 11-952, this amendment is in proper form and
is within the power and authority granted to the administration under §
A.R.S. 36-2903 et seq. and §36-2932 et seq.

Oct 23, 2020
Date:

Vises Del w-O). fs. we. =

within tl
pa Ae ‘
Deputy County Attorney

Leg4i counsel for the administration

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AHCCCS _YH08-0073

Administrative Annual Cost Estimates for Attachment A
Maricopa County Corrections 100% State IGA SFY21 ‘Amendment 12
Lol | 'C-26-08-011-0-12
Claims i Electronic | Paper Total Fund
90% 10% | 100%
Estimated total number of claims: | IL
Physician & Emergency Transport/Hospital | 18,050; 1,950 20,000 |
'DFSM Cost per Claim 2 § 0.65 = $ 0.75
OIG Provider Enrollment Cost per Claim 62g 0.14: $ 0.14
ISD Cost per Claim 2§ 1.59 $ 1.59 |
| Concurrent Review | Average Cost
Estimated cost per case 3 ¢ 127.95
‘Estimated number of HSAG reviews i 4
Claims Processing costs: Lod Ld
DFSM i $11,725.33 | $1,463.84 $13,189.17 |
OIG Provider Enrollment I $2,603.83 | $281.30 | $2,885.13 |
ISD | $28,685.68 $3,099.01 $31,784.69
State Accounting System Charges @ $0.1723/claim $3,110.33 | $336.02 $3,446.35
Total Claims Processing Costs i $46,125.17 $5,180.17 $51,305.34 |
Direct DFSM Labor for MDOC 100% State Claims Processing °, $100,943.94
‘Direct ISD Labor for MDOC 100% State Claims Processing 8 Lt $14,000.00
Concurrent Review Estimated costs: | |
| Cost for 4 reviews i i | $511.80,
‘Administrative Costs (see detail) |
DBF Paper Processing Personnel costs ul i $ 8,846.55 |
Postage @ $.0545/claim 8 $1,090.91
Data Center Charges @ $.7366/claim 9 $14,732.40 |
OOD @ $.2960/claim Lol i $5,920.74 |
OALS @ $.0821/claim il $1,642.14 |
HRD @ $.0251/claim Ll | | $501.61
TIBCO @ $.3307/claim | Lo $6,614.46 |
Indirect at 10% \ i $3,934.88
Total Administrative Costs | $ 43,283.69
DMS Eligibility Costs
Application Processing Costs - DMS 10 $0.00
Estimated Total Annual Costs for Program : | $210,044.77
Cost per Claim " i / $10.48

7 Actual number of claims may be higher. Number includes, original, recoupment and adjustment claims.

2 Cost based on actual SFY19 expenditures and actual number of claims processed

8 Average rate per contract. Actual costs will be a strict pass-through based on price negotiated on contract.

4 Actual number may be higher or low er depending on Maricopa Co 100% State program requirements.

5 Based on estimates of DFSM staff time required to process the claims. : i

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. i
® Postage based on average cost per claim times number of claims. {

° Data Center charges calculated based on average SFY 19 costs

|" DMS Bigibility charges calculated at $105/determination. Estimated 0 annual applications/determinations.

|" Cost per claim does not include a cost for concurrent review s

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