Common use of Provider Payment Clause in Contracts

Provider Payment. 4.10.4.1 With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including those Providers that may be paid a Capitation Payment. 4.10.4.2 The Contractor shall be responsible for issuing an IRS Form (1099) in accordance with all federal laws, regulations and guidelines. 4.10.4.3 When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.6 of the GF Contract, the Contractor shall pay the CAH a payment rate based on 101% allowable costs incurred by the CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s Appropriations Act. 4.10.4.3.1 A critical access hospital must provide notice to a care management organization and the Department of Community Health of any alleged breaches in its contract by such care management organization. 4.10.4.3.2 If a critical access hospital satisfies the requirement of Title 33 of the Official Code of Georgia Annotated (HB1234), and if the Department of Community Health concludes, after notice and hearing, that a care management organization has substantively and repeatedly breached a term of its contract with a critical access hospital, the department is authorized to require the care management organization to pay damages to the critical access hospital in an amount not to exceed three times the amount owed. Notwithstanding the foregoing, nothing in Title 33 of the Official Code of Georgia Annotated (HB1234) shall be interpreted to limit the authority of the Department of Community Health to establish additional penalties or fines against a care management organization for failure to comply with the contract between a care management organization and the Department of Community Health. 4.10.4.4 When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall, at minimum, pay the PPS rates for Core Services and other ambulatory services per encounter. The rates are established as described in §1001.1 of the Manual. At Contractor’s discretion, it may pay more than the PPS rate for these services. 4.10.4.4.1 Payment Reports must consist of all covered service claim types each month, inclusive of all of the below claims data: • Early and Periodic Screening, Diagnosis and Treatment • Physician Services • Office Visits • Laboratory Diagnostics • Radiology Diagnostics • Obstetrical Services • Family Planning Services • Injectable Drugs and Immunizations • Visiting Nurse Services • Newborn Hearing Screening • Hospitals • Nursing Homes • Other Clinics • Residential • Dental Services • Mental Health Clinic Services • Refractive Services • Pharmaceutical Services • Psychology Services • Podiatry Services • Pediatric Preventive Health Screening/Newborn Metabolic • Supplies incident to core services 4.10.4.5 Upon receipt of notice from DCH that it is due funds from a Provider, who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment to the Provider for all claims submitted by that Provider by one hundred percent (100%), or such other amount as DCH may elect, until such time as the amount owed to DCH is recovered. The Contractor shall promptly remit any such funds recovered to DCH in the manner specified by DCH. To that end, the Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH. 4.10.4.6 The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes to the Medical Assistance program, as directed by the Commissioner of DCH; to the extent, such adjustments can be made within funds appropriated to DCH and available for payment to the Contractor. The Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.

Provider Payment. 4.10.4.1 With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including those Providers that may be paid a Capitation Payment. 4.10.4.2 The Contractor shall be responsible for issuing an IRS Form (1099) in accordance with all federal laws, regulations and guidelines. 4.10.4.3 When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.6 4.8.5.2 of the GF Contract, the Contractor shall pay the CAH a payment rate based on 101% allowable costs incurred by the CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s Appropriations Act. 4.10.4.3.1 . · A critical access hospital must provide notice to a care management organization and the Department of Community Health DCH of any alleged breaches in its contract by such care management organization. 4.10.4.3.2 . · If a critical access hospital satisfies the requirement of Title 33 of the Official Code of Georgia Annotated (HB1234Medicaid Care Management Organizations Act), and if the Department of Community Health DCH concludes, after notice and hearing, that a care management organization has substantively and repeatedly breached a term of its contract with a critical access hospital, the department is authorized to require the care management organization to pay damages to the critical access hospital in an amount not to exceed three times the amount owed. Notwithstanding the foregoing, nothing in Title 33 of the Official Code of Georgia Annotated (HB1234Medicaid Care Management Organizations Act) shall be interpreted to limit the authority of the Department of Community Health DCH to establish additional penalties or fines against a care management organization for failure to comply with the contract between a care management organization and the Department of Community HealthDCH. 4.10.4.4 When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall, at minimum, shall pay the PPS rates for Core Services and other ambulatory services per encounter. The rates are established as described in §1001.1 of the Manual. At Contractor’s discretion, it may pay more than the PPS rate rates for these services. 4.10.4.4.1 Payment Reports must consist of all covered service claim types each month, inclusive of all of the below claims data: • · Early and Periodic Screening, Diagnosis and Treatment • · Physician Services • · Office Visits • · Laboratory Diagnostics • · Radiology Diagnostics • · Obstetrical Services • · Family Planning Services • · Injectable Drugs and Immunizations • · Visiting Nurse Services • · Newborn Hearing Screening • · Hospitals • · Nursing Homes • · Other Clinics • · Residential • · Dental Services • · Mental Health Clinic Services • · Refractive Services • Service · Pharmaceutical Services • · Psychology Services • · Podiatry Services • · Pediatric Preventive Health Screening/Newborn Metabolic • · Supplies incident to core services 4.10.4.5 Upon receipt of notice from DCH that it is due funds from a Provider, who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment to the Provider for all claims submitted by that Provider by one hundred percent (100%), or such other amount as DCH may elect, until such time as the amount owed to DCH is recovered. The Contractor shall promptly remit any such funds recovered to DCH in the manner specified by DCH. To that end, the Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH. 4.10.4.6 The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes to the Medical Assistance program, as directed by the Commissioner of DCH; to the extent, such adjustments can be made within funds appropriated to DCH and available for payment to the Contractor. The Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.

Provider Payment. 4.10.4.1 With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including those Providers that may be paid a Capitation Payment. 4.10.4.2 The Contractor shall be responsible for issuing an IRS Form (1099) in accordance with all federal laws, regulations and guidelines. 4.10.4.3 When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.6 4.8.5.2 of the GF Contract, the Contractor shall pay the CAH a payment rate based on 101% allowable costs incurred by the CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s Appropriations Act. 4.10.4.3.1 . · A critical access hospital must provide notice to a care management organization and the Department of Community Health DCH of any alleged breaches in its contract by such care management organization. 4.10.4.3.2 . · If a critical access hospital satisfies the requirement of Title 33 of the Official Code of Georgia Annotated (HB1234Medicaid Care Management Organizations Act), and if the Department of Community Health DCH concludes, after notice and hearing, that a care management organization has substantively and repeatedly breached a term of its contract with a critical access hospital, the department is authorized to require the care management organization to pay damages to the critical access hospital in an amount not to exceed three times the amount owed. Notwithstanding the foregoing, nothing in Title 33 of the Official Code of Georgia Annotated (HB1234Medicaid Care Management Organizations Act) shall be interpreted to limit the authority of the Department of Community Health DCH to establish additional penalties or fines against a care management organization for failure to comply with the contract between a care management organization and the Department of Community HealthDCH. 4.10.4.4 When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall, at minimum, shall pay the PPS rates for Core Services and other ambulatory services per encounter. The rates are established as described in §1001.1 of the Manual. At Contractor’s discretion, it may pay more than the PPS rate rates for these services. 4.10.4.4.1 Payment Reports must consist of all covered service claim types each month, inclusive of all of the below claims data: • · Early and Periodic Screening, Diagnosis and Treatment • · Physician Services • · Office Visits • · Laboratory Diagnostics • · Radiology Diagnostics • · Obstetrical Services • · Family Planning Services • · Injectable Drugs and Immunizations • · Visiting Nurse Services • · Newborn Hearing Screening • · Hospitals • · Nursing Homes • · Other Clinics • · Residential • · Dental Services • · Mental Health Clinic Services • · Refractive Services • · Pharmaceutical Services • · Psychology Services • · Podiatry Services • · Pediatric Preventive Health Screening/Newborn Metabolic • · Supplies incident to core servicesservices · Demonstration related Services as a separate report 4.10.4.5 Upon receipt of notice from DCH that it is due funds from a Provider, who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment to the Provider for all claims submitted by that Provider by one hundred percent (100%), or such other amount as DCH may elect, until such time as the amount owed to DCH is recovered. The Contractor shall promptly remit any such funds recovered to DCH in the manner specified by DCH. To that end, the Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH. 4.10.4.6 The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes to the Medical Assistance program, as directed by the Commissioner of DCH; to the extent, such adjustments can be made within funds appropriated to DCH and available for payment to the Contractor. The Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.

Provider Payment. 4.10.4.1 With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including those Providers that may be paid a Capitation Payment.. Revised 5/19/2008 4.10.4.2 The Contractor shall be responsible for issuing an IRS Form (1099) in accordance with all federal laws, regulations and guidelines. 4.10.4.3 When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.6 of the GF Contract, the Contractor shall pay the CAH a payment rate based on 101% allowable costs incurred by the CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s 's Appropriations Act. 4.10.4.3.1 A critical access hospital must provide notice to a care management organization and the Department of Community Health of any alleged breaches in its contract by such care management organization. 4.10.4.3.2 If a critical access hospital satisfies the requirement of Title 33 3 3 of the Official Code of Georgia Annotated (HB1234), and if the Department of Community Health concludes, after notice and hearing, that a care management organization has substantively and repeatedly breached a term of its contract with a critical access hospital, the department is authorized to require the care management organization to pay damages to the critical access hospital in an amount not to exceed three times the amount owed. Notwithstanding the foregoing, nothing in Title 33 of the Official Code of Georgia Annotated (HB1234) shall be interpreted to limit the authority of the Department of Community Health to establish additional penalties or fines against a care management organization for failure to comply with the contract between a care management organization and the Department of Community Health. 4.10.4.4 When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall, at minimum, shall pay the PPS rates for Core Services and other ambulatory services per encounter. The rates are established as described in §1001.1 of the Manual. At Contractor’s 's discretion, it may pay more than the PPS rate rates for these services. 4.10.4.4.1 Payment Reports must consist of all covered service claim types each month, inclusive of all of the below claims data: • Early and Periodic Screening, Diagnosis and Treatment • Physician Services • Office Visits • Laboratory Diagnostics • Radiology Diagnostics • Obstetrical Services • Family Planning Services • Revised 5/19/2008 Injectable Drugs and Immunizations • Visiting Nurse Services • Newborn Hearing Screening • Hospitals • Nursing Homes • Other Clinics • Residential • Dental Services • Mental Health Clinic Services • Refractive Services • Pharmaceutical Services • Psychology Services • Podiatry Services • Pediatric Preventive Health Screening/Newborn Metabolic • Supplies incident to core services 4.10.4.5 Upon receipt of notice from DCH that it is due funds from a Provider, who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment to the Provider for all claims submitted by that Provider by one hundred percent (100%), or such other amount as DCH may elect, until such time as the amount owed to DCH is recovered. The Contractor shall promptly remit any such funds recovered to DCH in the manner specified by DCH. To that end, the Contractor’s 's Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s 's execution of the Contract shall constitute agreement with the Contractor’s 's obligation to DCH. 4.10.4.6 The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes to the Medical Assistance program, as directed by the Commissioner of DCH; to the extent, such adjustments can be made within funds appropriated to DCH and available for payment to the Contractor. The Contractor’s 's Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s 's execution of the Contract shall constitute agreement with the Contractor’s 's obligation to DCH.

Provider Payment. 4.10.4.1 With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including those Providers that may be paid a Capitation Payment. 4.10.4.2 The Contractor shall be responsible for issuing an IRS Form (1099) in accordance with all federal laws, regulations and guidelines. 4.10.4.3 When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.6 4.8.5.2 of the GF Contract, the Contractor shall pay the CAH a payment rate based on 101% allowable costs incurred by the CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s Appropriations Act. 4.10.4.3.1 . · A critical access hospital must provide notice to a care management organization and the Department of Community Health DCH of any alleged breaches breache in its contract contrct by such care management organization. 4.10.4.3.2 . · If a critical access hospital satisfies the requirement of Title 33 of the Official Code of Georgia Annotated (HB1234Medicaid Care Management Organizations Act), and if the Department of Community Health DCH concludes, after notice and hearing, that a care management organization has substantively and repeatedly breached a term of its contract with a critical access hospital, the department is authorized to require the care management organization to pay damages to the critical access hospital in an amount not to exceed three times the amount owed. Notwithstanding the foregoing, nothing in Title 33 of the Official Code of Georgia Annotated (HB1234Medicaid Care Management Organizations Act) shall be interpreted to limit the authority of the Department of Community Health DCH to establish additional penalties or fines against a care management organization for failure to comply with the contract between a care management organization and the Department of Community HealthDCH. 4.10.4.4 When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall, at minimum, shall pay the PPS rates for Core Services and other ambulatory services per encounter. The rates are established as described in §1001.1 of the Manual. At Contractor’s discretion, it may pay more than the PPS rate rates for these services. 4.10.4.4.1 Payment Reports must consist of all covered service claim types each month, inclusive of all of the below claims data: • · Early and Periodic Screening, Diagnosis and Treatment • · Physician Services • · Office Visits • · Laboratory Diagnostics • · Radiology Diagnostics • · Obstetrical Services • · Family Planning Services • · Injectable Drugs and Immunizations • · Visiting Nurse Services • · Newborn Hearing Screening • · Hospitals • · Nursing Homes • · Other Clinics • · Residential • · Dental Services • · Mental Health Clinic Services • · Refractive Services • · Pharmaceutical Services • · Psychology Services • · Podiatry Services • · Pediatric Preventive Health Screening/Newborn Metabolic • · Supplies incident to core servicesservices · Demonstration related Services as a separate report 4.10.4.5 Upon receipt of notice from DCH that it is due funds from a Provider, who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment to the Provider for all claims submitted by that Provider by one hundred percent (100%), or such other amount as DCH may elect, until such time as the amount owed to DCH is recovered. The Contractor shall promptly remit any such funds recovered to DCH in the manner specified by DCH. To that end, the Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH. 4.10.4.6 The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes to the Medical Assistance program, as directed by the Commissioner of DCH; to the extent, such adjustments can be made within funds appropriated to DCH and available for payment to the Contractor. The Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.

Provider Payment. 4.10.4.1 With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including those Providers that may be paid a Capitation Payment. 4.10.4.2 The Contractor shall be responsible for issuing an IRS Form (1099) in accordance with all federal laws, regulations and guidelines. 4.10.4.3 When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.6 4.8.5.2 of the GF Contract, the Contractor shall pay the CAH a payment rate based on 101% allowable costs incurred by the CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s Appropriations Act. 4.10.4.3.1 . • A critical access hospital must provide notice to a care management organization and the Department of Community Health DCH of any alleged breaches breache in its contract contrct by such care management organization. 4.10.4.3.2 . • If a critical access hospital satisfies the requirement of Title 33 of the Official Code of Georgia Annotated (HB1234Medicaid Care Management Organizations Act), and if the Department of Community Health DCH concludes, after notice and hearing, that a care management organization has substantively and repeatedly breached a term of its contract with a critical access hospital, the department is authorized to require the care management organization to pay damages to the critical access hospital in an amount not to exceed three times the amount owed. Notwithstanding the foregoing, nothing in Title 33 of the Official Code of Georgia Annotated (HB1234Medicaid Care Management Organizations Act) shall be interpreted to limit the authority of the Department of Community Health DCH to establish additional penalties or fines against a care management organization for failure to comply with the contract between a care management organization and the Department of Community HealthDCH. 4.10.4.4 When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall, at minimum, shall pay the PPS rates for Core Services and other ambulatory services per encounter. The rates are established as described in §1001.1 of the Manual. At Contractor’s discretion, it may pay more than the PPS rate rates for these services. 4.10.4.4.1 Payment Reports must consist of all covered service claim types each month, inclusive of all of the below claims data: • Early and Periodic Screening, Diagnosis and Treatment • Physician Services • Office Visits • Laboratory Diagnostics • Radiology Diagnostics • Obstetrical Services • Family Planning Services • Injectable Drugs and Immunizations • Visiting Nurse Services • Newborn Hearing Screening • Hospitals • Nursing Homes • Other Clinics • Residential • Dental Services • Mental Health Clinic Services • Refractive Services • Pharmaceutical Services • Psychology Services • Podiatry Services • Pediatric Preventive Health Screening/Newborn Metabolic • Supplies incident to core servicesservices • Demonstration related Services as a separate report 4.10.4.5 Upon receipt of notice from DCH that it is due funds from a Provider, who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment to the Provider for all claims submitted by that Provider by one hundred percent (100%), or such other amount as DCH may elect, until such time as the amount owed to DCH is recovered. The Contractor shall promptly remit any such funds recovered to DCH in the manner specified by DCH. To that end, the Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH. 4.10.4.6 The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes to the Medical Assistance program, as directed by the Commissioner of DCH; to the extent, such adjustments can be made within funds appropriated to DCH and available for payment to the Contractor. The Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.

Provider Payment. 4.10.4.1 With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including those Providers that may be paid a Capitation Payment. 4.10.4.2 The Contractor shall be responsible for issuing an IRS Form (1099) in accordance with all federal laws, regulations and guidelines. 4.10.4.3 When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.6 of the GF Contract, the Contractor shall pay the CAH a payment rate based on 101% allowable costs incurred by the CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s Appropriations Act. 4.10.4.3.1 A critical access hospital must provide notice to a care management organization and the Department of Community Health of any alleged breaches in its contract by such care management organization. 4.10.4.3.2 If a critical access hospital satisfies the requirement of Title 33 of the Official Code of Georgia Annotated (HB1234), and if the Department of Community Health concludes, after notice and hearing, that a care management organization has substantively and repeatedly breached a term of its contract with a critical access hospital, the department is authorized to require the care management organization to pay damages to the critical access hospital in an amount not to exceed three times the amount owed. Notwithstanding the foregoing, nothing in Title 33 of the Official Code of Georgia Annotated (HB1234) shall be interpreted to limit the authority of the Department of Community Health to establish additional penalties or fines against a care management organization for failure to comply with the contract between a care management organization and the Department of Community Health. 4.10.4.4 When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall, at minimum, shall pay the PPS rates for Core Services and other ambulatory services per encounter. The rates are established as described in §1001.1 of the Manual. At Contractor’s discretion, it may pay more than the PPS rate rates for these services. 4.10.4.4.1 Payment Reports must consist of all covered service claim types each month, inclusive of all of the below claims data: • Early and Periodic Screening, Diagnosis and Treatment • Physician Services • Office Visits • Laboratory Diagnostics • Radiology Diagnostics • Obstetrical Services • Family Planning Services • Injectable Drugs and Immunizations • Visiting Nurse Services • Newborn Hearing Screening • Hospitals • Nursing Homes • Other Clinics • Residential • Dental Services • Mental Health Clinic Services • Refractive Services • Pharmaceutical Services • Psychology Services • Podiatry Services • Pediatric Preventive Health Screening/Newborn Metabolic • Supplies incident to core servicesservices (SEE DCH MEDICIAD MANUAL FOR ADDITIONAL INFORMATION ON FQHCs AND RHCs REQUIREMENTS: ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇▇▇▇▇.▇▇▇/wps/output/en_US/public/Provider/MedicaidManuals/01_2008_RHC_v2.pdf 4.10.4.5 Upon receipt of notice from DCH that it is due funds from a Provider, who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment to the Provider for all claims submitted by that Provider by one hundred percent (100%), or such other amount as DCH may elect, until such time as the amount owed to DCH is recovered. The Contractor shall promptly remit any such funds recovered to DCH in the manner specified by DCH. To that end, the Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH. 4.10.4.6 The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes to the Medical Assistance program, as directed by the Commissioner of DCH; to the extent, such adjustments can be made within funds appropriated to DCH and available for payment to the Contractor. The Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.

Provider Payment. 4.10.4.1 With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including those Providers that may be paid a Capitation Payment. 4.10.4.2 The Contractor shall be responsible for issuing an IRS Form (1099) in accordance with all federal laws, regulations and guidelines. 4.10.4.3 When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.6 4.8.5.2 of the GF Contract, the Contractor shall pay the CAH a payment rate based on 101% allowable costs incurred by the CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s Appropriations Act. 4.10.4.3.1 . • A critical access hospital must provide notice to a care management organization and the Department of Community Health DCH of any alleged breaches in its contract by such care management organization. 4.10.4.3.2 . • If a critical access hospital satisfies the requirement of Title 33 of the Official Code of Georgia Annotated (HB1234Medicaid Care Management Organizations Act), and if the Department of Community Health DCH concludes, after notice and hearing, that a care management organization has substantively and repeatedly breached a term of its contract with a critical access hospital, the department is authorized to require the care management organization to pay damages to the critical access hospital in an amount not to exceed three times the amount owed. Notwithstanding the foregoing, nothing in Title 33 of the Official Code of Georgia Annotated (HB1234Medicaid Care Management Organizations Act) shall be interpreted to limit the authority of the Department of Community Health DCH to establish additional penalties or fines against a care management organization for failure to comply with the contract between a care management organization and the Department of Community HealthDCH. 4.10.4.4 When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall, at minimum, shall pay the PPS rates for Core Services and other ambulatory services per encounter. The rates are established as described in §1001.1 of the Manual. At Contractor’s discretion, it may pay more than the PPS rate rates for these services. 4.10.4.4.1 Payment Reports must consist of all covered service claim types each month, inclusive of all of the below claims data: • Early and Periodic Screening, Diagnosis and Treatment • Physician Services • Office Visits • Laboratory Diagnostics • Radiology Diagnostics • Obstetrical Services • Family Planning Services • Injectable Drugs and Immunizations • Visiting Nurse Services • Newborn Hearing Screening • Hospitals • Nursing Homes • Other Clinics • Residential • Dental Services • Mental Health Clinic Services • Refractive Services • Pharmaceutical Services • Psychology Services • Podiatry Services • Pediatric Preventive Health Screening/Newborn Metabolic • Supplies incident to core servicesservices • Demonstration related Services as a separate report 4.10.4.5 Upon receipt of notice from DCH that it is due funds from a Provider, who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment to the Provider for all claims submitted by that Provider by one hundred percent (100%), or such other amount as DCH may elect, until such time as the amount owed to DCH is recovered. The Contractor shall promptly remit any such funds recovered to DCH in the manner specified by DCH. To that end, the Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH. 4.10.4.6 The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes to the Medical Assistance program, as directed by the Commissioner of DCH; to the extent, such adjustments can be made within funds appropriated to DCH and available for payment to the Contractor. The Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.

Provider Payment. 4.10.4.1 With the exceptions noted below, the Contractor shall negotiate rates with Providers and such rates shall be specified in the Provider Contract. DCH prefers that Contractors pay Providers on a Fee for Service basis, however if the Contractor does enter into a capitated arrangement with Providers, the Contractor shall continue to require all Providers to submit detailed Encounter Data, including those Providers that may be paid a Capitation Payment. 4.10.4.2 The Contractor shall be responsible for issuing an IRS Form (1099) in accordance with all federal laws, regulations and guidelines. 4.10.4.3 When the Contractor negotiates a contract with a Critical Access Hospital (CAH), pursuant to Section 4.8.6 4.8.5.2 of the GF Contract, the Contractor shall pay the CAH a payment rate based on 101% allowable costs incurred by the CAH. DCH may require the Contractor to adjust the rate paid to CAHs if so directed by the State of Georgia’s Appropriations Act. 4.10.4.3.1 . · A critical access hospital must provide notice to a care management organization and the Department of Community Health DCH of any alleged breaches in its contract by such care management organization. 4.10.4.3.2 . · If a critical access hospital satisfies the requirement of Title 33 of the Official Code of Georgia Annotated (HB1234Medicaid Care Management Organizations Act), and if the Department of Community Health DCH concludes, after notice and hearing, that a care management organization has substantively and repeatedly breached a term of its contract with a critical access hospital, the department is authorized to require the care management organization to pay damages to the critical access hospital in an amount not to exceed three times the amount owed. Notwithstanding the foregoing, nothing in Title 33 of the Official Code of Georgia Annotated (HB1234Medicaid Care Management Organizations Act) shall be interpreted to limit the authority of the Department of Community Health DCH to establish additional penalties or fines against a care management organization for failure to comply with the contract between a care management organization and the Department of Community HealthDCH. 4.10.4.4 When the Contractor negotiates a contract with a FQHC and/or a RHC, as defined in Section 1905(a)(2)(B) and 1905(a)(2)(C) of the Social Security Act, the Contractor shall, at minimum, shall pay the PPS rates for Core Services and other ambulatory services per encounter. The rates are established as described in §1001.1 of the Manual. At Contractor’s discretion, it may pay more than the PPS rate rates for these services. 4.10.4.4.1 Payment Reports must consist of all covered service claim types each month, inclusive of all of the below claims data: • · Early and Periodic Screening, Diagnosis and Treatment • · Physician Services • · Office Visits • · Laboratory Diagnostics • · Radiology Diagnostics • · Obstetrical Services • · Family Planning Services • · Injectable Drugs and Immunizations • · Visiting Nurse Services • · Newborn Hearing Screening • · Hospitals • · Nursing Homes • · Other Clinics • · Residential • · Dental Services • · Mental Health Clinic Services • · Refractive Services • · Pharmaceutical Services • · Psychology Services • · Podiatry Services • · Pediatric Preventive Health Screening/Newborn Metabolic • Supplies incident to core services 4.10.4.5 Upon receipt of notice from DCH that it is due funds from a Provider, who has exhausted or waived the administrative review process, if applicable, the Contractor shall reduce payment to the Provider for all claims submitted by that Provider by one hundred percent (100%), or such other amount as DCH may elect, until such time as the amount owed to DCH is recovered. The Contractor shall promptly remit any such funds recovered to DCH in the manner specified by DCH. To that end, the Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH. 4.10.4.6 The Contractor shall adjust its negotiated rates with Providers to reflect budgetary changes to the Medical Assistance program, as directed by the Commissioner of DCH; to the extent, such adjustments can be made within funds appropriated to DCH and available for payment to the Contractor. The Contractor’s Provider Contracts shall contain a provision giving notice of this obligation to the Provider, such that the Provider’s execution of the Contract shall constitute agreement with the Contractor’s obligation to DCH.