STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES AND AMERIGROUP NEW JERSEY, INC. AGREEMENT TO PROVIDE HMO SERVICES

Exhibit 10.6.9

STATE OF NEW JERSEY

DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

AND

AMERIGROUP NEW JERSEY, INC.

AGREEMENT TO PROVIDE HMO SERVICES

In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract between AMERIGROUP New Jersey, Inc. and the State of New Jersey, Department of Human Services, Division of Medical Assistance and Health Services (DMAHS), effective date October 1, 2000, all parties agree that the contract shall be amended, effective July 1, 2005, as follows:

Exhibit 10.6.9

1.

Article 1, “Definitions” section — for the following definition:

1.

Capitation Summary Record (new definition)

shall be amended as reflected in the relevant page of Article 1 attached hereto and incorporated herein.

	2.		Article 2, “Conditions Precedent” Sections H and K.1(b) shall be amended as reflected in Article 2, Sections H and K.1(b) attached hereto and incorporated herein.
	3.		Article 3, “Managed Care Management Information System,” Sections 3.2(C); 3.2.1(B); 3.2.5; 3.3.1(A); 3.3.3(A); 3.4.4 (new); 3.9(A); 3.9(C); 3.9.1(A) (new); 3.9.1(B); 3.9.1(C) (deleted); 3.9.2(A); 3.9.2(B); 3.9.3(C); 3.9.3(D) (deleted), re-number remaining; 3.9.3(E) (new); 3.9.4(A) and 3.9.4(B) shall be amended as reflected in Article 3, Sections 3.2(C), 3.2.1(B), 3.2.5, 3.3.1(A), 3.3.3(A), 3.4.4, 3.9(A), 3.9(C), 3.9.3(D), 3.9.3(E), 3.9.4(A) and 3.9.4(B) attached hereto and incorporated herein.
	4.		Article 4, “Provision of Health Care Services” Sections 4.1.1(G)4 (new); 4.1.2(A)18; 4.2.1(K)3 (new); 4.2.6(A)6 (deleted); 4.2.6(B)1(c); 4.2.6(B)7(f); 4.2.6(B)7(f)ii. 1); 4.3.3(A); 4.5.2(B); 4.5.4(B); 4.6.1(C)8 (new) 4.6.2(P); 4.6.2(X) (new) (deleted previous); 4.6.2(AA)1 (new); 4.6.4(C); 4.6.4(C)6(c); 4.6.4(C)6(d); 4.7.1(K) (new); 4.7.2(A)1; 4.8.3; 4.8.3(A), 4.8.3(A)3 (new); 4.8.3(C)1(new); 4.8.7(D) and 4.8.8(G)1 shall be amended as reflected in Article 4, Sections 4.1.1(G)4, 4.1.2(A)18, 4.2.1(K)3, 4.2.6(A)6, 4.2.6(B)1(c), 4.2.6(B)7(f)ii.1), 4.3.3(A), 4.5.2(B), 4.5.4(B), 4.6.1(C)8, 4.6.2(P), 4.6.2(X), 4.6.2(AA)1, 4.6.4(C), 4.6.4(C)6(c), 4.6.4(C)6(d), 4.7.1(K), 4.7.2(A)1, 4.8.3, 4.8.3(A), 4.8.3(A)3, 4.8.3(C)1, 4.8.7(D) and 4.8.8(G)1 attached hereto and incorporated herein.
	5.		Article 5, “Enrollee Services” Sections 5.8.2(S); 5.8.2(NN); 5.10.2(A)1; 5. 14.2(B)8 and 5.15.3(D) shall be amended as reflected in article 5, Sections 5.8.2(S), 5.8.2(NN), 5.10.2(A)1, 5.15.2(B)8 and 5.15.3(D) attached hereto and incorporated herein.
	6.		Article 7, “Terms and Conditions” Sections 7.3(A); 7.16.4; 7.16.5; 7.16.7(B)2 (new); 7.16.7(B)3 (new); 7.26(F); 7.27.1(B) and 7.38.2(A)1 shall be amended as reflected in Article 7,

Exhibit 10.6.9

			Sections 7.3(A), 7.16.4, 7.16.5, 7.16.7(B)2, 7.16.7(B)3, 7.26(F), 7.27.1(B) and 7.38.2(A)1 attached hereto and incorporated herein.
	7.		Article 8, “Financial Provisions”, Sections 8.4.1(A); 8.4.1(A)1; 8.4.1(A)2; 8.4.1(A)3; 8.5.2.1; 8.5.2.4; 8.5.4 (Heading) 8.5.8 (deleted) (Reserved) and 8.7(H)3 shall be amended as reflected in Article 8, Sections 8.4.1(A), 8.4.1(A)1, 8.4.1(A)2, 8.4.1(A)3, 8.5.2.1, 8.5.2.4, 8.5.4, 8.5.5 and 8.7(H)3 attached hereto and incorporated herein.
	8.		Appendix, Section A, “Reports”
	•		A.3.1 — Reserved (deleted previous);
	•		A.4.1 — Provider Network File: Attachment A, #▇▇, #▇▇, #▇▇, #▇▇, #▇▇, #▇▇, #▇▇, #▇▇ (▇▇▇); Attachment B, #16, #18 (new); Attachment E (revised);
	•		A.4.3 — Network Accessibility Analysis for New Jersey Medicaid/NJ FamilyCare, B.3 #1, 2, 3, 8, 10, 11, 12 (footnote added to define “na”);
	•		A.7.1 — Certifications, A.7.1(A); A.7.1(B); A.7.1(C) revised language; A.7.1(E) (new);
	•		A.7.2 — Fraud and Abuse (deleted Section C);
	•		A.7.3 — Table 1; (revised);
	•		A.7.4 — Reserved (deleted previous);
	•		A.7.6 — Reserved (Table 4 moved to HMO Financial Reporting Manual);
	•		A.7.7 — Table 5; narrative revised;
	•		A.7.8 — Table 6: 6a, 6b, 6d and 6e moved to HMO Financial Reporting Manual; 6c renamed;
	•		A.7.9 — Reserved (Table 7 moved to HMO Financial Reporting Manual);
	•		A.7.10 — Reserved (deleted previous);
	•		A.7.11 — Table 9: Semi-Annual Utilization and Medical Expenditure Summary (new), (deleted previous);
	•		A.7.13 — Reserved (deleted previous);
	•		A.7.16 — Reserved (deleted previous);
	•		A.7.18 — Table 16 (revised);
	•		A.7.21 — HMO Financial Reporting Manual for Medicaid/NJ FamilyCare Rate Cell Grouping Costs, (revised) (moved from B.7.3, incorporates revised Table 19;

Exhibit 10.6.9

	•		A.7.22 — Reserved (Table 20 moved to Financial Reporting Manual);
	•		A.7.23 — Reserved (Table 21 moved to Financial Reporting Manual);
	•		A.8.3 — Estate Referral Form — (report separated from previous A.8.2)

shall be amended as reflected in Appendix, Section A, A.3.1, A.4.1, A.4.3, A.7.1, A.7.2, A.7.3, A.7.4, A.7.6, A.7.7, A.7.9, A.7.9, A.7.10, A.7.11, A.7.12, A.7.13, A.7.16, A.7.18, A.7.21, A.7.22, A.7.23 and A.8.3 attached hereto and incorporated herein.

	9.		Appendix, Section B, “Reference Materials”
	•		B.3.1 — Reserved (deleted previous);
	•		B.3.2 — Data Files Resources Guide (new) (deleted previous);
	•		B.4.6 — School-Based Youth Services Programs — list replaced with web site address;
	•		B.4.7 — Local Health Departments — list replaced with web site address;
	•		B.4.9 — Mental Health/Substance Abuse Screening Tool
	•		B.4.11—Special Child Health Services Network — list replaced with web site address;
	•		B.4.13 — Statewide Family Centered HIV Care network (▇▇▇▇ ▇▇▇▇▇ Title IV) — list replaced with web site address;
	•		B.5.2 — Cost sharing Requirements for NJ FamilyCare Plan H:#4 deleted, renumber remaining;
	•		B.57.3 — Reserved (previous moved to A.7.21), and
	•		B.7.4 — Reserved

shall be amended as reflected in Appendix, Section B, B.3.1, B.3.2, B.4.6, B.4.7, B.4.9, B.4.11, B.4.13, B.5.2, B.7.3 and B.7.4 attached hereto and incorporated herein.

	10.		Appendix, Section C, “Capitation Rates” shall be revised as reflected in SFY 2005 Capitation Rates attached hereto and incorporated herein.
	11.		Appendix, Section E, “Managed Care Service Administrator (MCSA) Administrative Fees” shall be revised as reflected in the SFY 2005 Administrative Fees attached hereto and incorporated herein.

Exhibit 10.6.9

12.

All other terms and conditions of the October 1, 2000 contract and subsequent amendments remain unchanged except as noted above.

The contracting parties indicate their agreement by their signatures.

	Amerigroup New Jersey, Inc				State of New Jersey Department of Human Services
	BY:		/s/      TBD		BY:		/s/ ▇▇▇ Clemency Kohler
	TITLE: President and CEO				TITLE: Director, DMAHS
	DATE: /s/ April 28, 2005				DATE: /s/ 5/2/05
	APPROVED AS TO FORM ONLY Attorney General State of New Jersey
	BY:		/s/      TBD
	Deputy Attorney General
	DATE: /s/ 4/29/05

Exhibit 10.6.9

C. The Bureau of Guardianship Services (BGS); or

D. A person or agency who has been duly designated by a power of attorney for medical decisions made on behalf of an enrollee.

Throughout the contract, information regarding enrollee rights and responsibilities can be taken to include authorized person, whether stated as such or not.

Automatic Assignment — The enrollment of an eligible person, for whom enrollment is mandatory, in a managed care plan chosen by the New Jersey Department of Human Services pursuant to the provisions of Article 5.4 of this contract.

Basic Service Area — the geographic area in which the contractor is obligated to provide covered services for its Medicaid/NJ FamilyCare enrollees under this contract.

Beneficiary — any person eligible to receive services in the New Jersey Medicaid/NJ FamilyCare program

Benefits Package — the health care services set forth in this contract, for which the contractor has agreed to provide, arrange, and be held fiscally responsible.

Bilingual — see “Multilingual”

Bonus — a payment the contractor makes to a physician or physician group beyond any salary, fee-for-service payments, capitation or returned withholding amount.

Capitated Service — any covered service for which the contractor receives capitation payment

Capitation — a contractual agreement through which a contractor agrees to provide specified health care services to enrollees for a fixed amount per month.

Capitation Payments — the amount prepaid monthly by DMAHS to the contractor in exchange for the delivery of covered services to enrollees based on a fixed Capitation Rate per

Exhibit 10.6.9

enrollee, notwithstanding (a) the actual number of enrollees who receive services from the contractor, or (b) the amount of services provided to any enrollee.

Capitation Rate — the fixed monthly amount that the contractor is prepaid by the Department for each enrollee for which the contractor provides the services included in the Benefits Package described in this contract.

Capitation Summary Record — pseudo-encounters that are reported in addition to normal encounters. They represent a financial summary of the reported services rendered by HMO network providers, where the contractual relationship between the HMO and the network provider is based on a periodic capitation payment, and not on a pre-determined fee for a rendered service.

Exhibit 10.6.9

2. The contractor shall comply with and remain in compliance with minimum net worth and fiscal solvency and reporting requirements of the Department of Banking and Insurance, the Department of Human Services, the federal government, and this contract.

3. The contractor shall provide written certification of new written contracts for all providers other than FQHCs and shall provide copies of fully executed contracts for new contracts with FQHCs on a quarterly basis.

4. If solvency protection arrangements change, the contractor shall notify the DMAHS sixty (60) days before such change takes effect and provide written copy of DOBI approval.

2.H. County Expansion Phase-In Plan. If the contractor does not have an approved COA for each of the counties in a designated region, the contractor shall submit to DMAHS a county expansion phase-in plan for review and approval by DMAHS prior to the execution of this contract. The plan shall include detailed information of:

	•		The region and names of the counties targeted for expansion;
	•		Anticipated dates of the submission of the COA modification to DOBI and DHSS (with copies to DMAHS);
	•		Anticipated date of approval of the COA;
	•		Anticipated date for full operations in the region;
	•		Anticipated date for initial beneficiary enrollment in each county

The phase-in plan shall indicate that when full expansion into a region shall be complete by June 30, 2004. All expansions are subject to approval by DMAHS. The contractor shall maintain full coverage for each county in each region in which the contractor operates for the duration of this contract.

I. No court order, administrative decision, or action by any other instrumentality of the United State Government or the State of New Jersey or any other state is outstanding which prevents implementation of this contract.

J. Net Worth

Exhibit 10.6.9

          1. The contractor shall maintain a minimum net worth in accordance with N.J.A.C. Title 8:38-11 et seq.

          2. The Department shall have the right to conduct targeted financial audits of the contractor’s Medicaid/NJ FamilyCare line of business. The contractor shall provide the Department with financial data, as requested by the Department, within a time frame specified by the Department.

2K. The contractor shall comply with the following financial operations requirements:

1.

A contractor shall establish and maintain:

	a.		An office in New Jersey, and
	b.		Premium and claims accounts in a New Jersey qualified bank with a principal office in New Jersey as approved by DOBI.

2.

The contractor shall have a fiscally sound operation as demonstrated by:

	a.		Maintenance of a minimum net worth in accordance with DOBI requirements (total line of business) and the requirements outlined in G and J above and Article 8.2.
	b.		Maintenance of a net operating surplus for Medicaid/NJ FamilyCare line of business. If the contractor fails to earn a net operating surplus during the most recent calendar year or does not maintain minimum net worth requirements on a quarterly basis, it shall submit a plan of action to DMAHS within the time fram especified by the Department. The plan is subject to the approval of DMAHS. It shall demonstrate how and when minimum net worth will be replenished and present marketing and financial projections. These shall be supported by suitable back-up material. The discussion shall include possible alternate funding sources, including invoking of corporate parental guarantee. The plan will include:

	i.		A detailed marketing plan with enrollment projections for the next two years.
	ii.		A projected balance sheet for the next two years.
	iii.		A projected statement of revenues and expenses on an accrual basis for the next two years.

Exhibit 10.6.9

	iv.		A statement of cash flow projected for the next two years.
	v.		A description of how to maintain capital requirements and replenish net worth.
	vi.		Sources and timing of capital shall be specifically identified.

3.

The contractor may be required to obtain prior to this contract and maintain “Stop-Loss” insurance, pursuant to provisions in Article 8.3.2.

Exhibit 10.6.9

frames and format requirements are in Section A of the Appendices.

B. Ad Hoc Reporting. The contractor shall have the capability to support ad hoc reporting requests, in addition to those listed in this contract, both from its own organization and from the State in a reasonable time frame. The time frame for submission of the report will be determined by DMAHS with input from the contractor based on the nature of the report. DMAHS shall at its option request six (6) to eight (8) reports per year, hardcopy or electronic reports and/or file extracts. This does not preclude or prevent DMAHS from requiring, or the contractor from providing, additional reports that are required by State or federal governmental entities or any court of competent jurisdiction.

C. System Documentation. The contractor shall update documentation on its system(s) within 30 days of implementation of the changes. The contractor’s documentation must include a system introduction, program overviews, operating environment, external interfaces, and data element dictionary. For each of the functional components, the documentation should include where applicable program narratives, processing flow diagrams, forms, screens, reports, files, detailed logic such as claims pricing algorithms and system edits. The documentation should also include job descriptions and operations instructions. The contractor shall have available current documentation on-site for Staet audit as requested.

3.1.4 OTHER REQUIREMENTS

     Future Changes. The system shall be easily modifiable to accommodate future system changes/enhancements to claims processing or other related systems at the same time as changes take place in the State’s MMIS. In addition, the system shall be able to accommodate all future requirements based upon federal and State statues, policies and regulations. Unless otherwise agreed by the State, the contractor shall be responsible for the costs of these changes.

3.2 ENROLLEE SERVICES

Exhibit 10.6.9

The MCMIS shall support all of the enrollee services as specified in Article 5 of this contract. The system shall:

	A.		Capture and maintain contractor enrollment data electronically.
	B.		Provide information so that the contractor can send plan materials and information to enrollees.
	C.		Capture electronically the Primary Care Provider (PCP) selections name provided by enrollees as well as enrollee health profiles from the Health Benefits Coordinator and/or the State.
	D.		Provide contractor enrollment and Medicaid information to providers.
	E.		Maintain an enrollee complaint and grievance tracking system for Medicaid and NJ FamilyCare enrollees.
	F.		Produce the required enrollee data reports.

The enrollee module(s) shall interface with all other required modules and permit the access, search, and retrieval of enrollee data by key fields, including date-sensitive information.

3.2.1 CONTRACTOR ENROLLMENT DATA

A. Enrollee Data. The contractor shall maintain a complete history of enrollee information, including contractor enrollment , primary care provider selection or assignment, third party liability coverage, and Medicare coverage. In addition, the contractor shall capture demographic information relating to the enrollee (age, sex, county, etc.), information related to family linkages, information relating to benefit and service limitations, and information related to health care for enrollees with special needs.

B. Updates. The contractor shall accept and process a weekly enrollment and eligibility file information according to HIPPA standards (the managed care register files; See section B.3.2 of the Appendices) within 48 hours of receipt from the Department. Details of the 834 daily, weekly, and monthly files are available in the HIPAA Implementation and New Jersey Medicaid Companion Guides. The system shall provide reports that identify all errors encountered, count all transactions processed, and provide for a complete audit trail of the update processes. The MCMIS shall accommodate the following specific Medicaid/NJ FamilyCare requirements.

Exhibit 10.6.9

     1. The contractor shall be able to access and identify all enrollees by their Medicaid/NJ FamilyCare Identification Number. This number shall be readily cross-referenced to the contractor’s enrollment number and the enrollee’s social security number. For DYFS cases, it is important that the contractor’s system be able to distinguish the DYFS enrolled children not be consolidated based on the first 10 digits of the Medicaid ID number because the family members may not be residing together.

2. The system shall be able to link family members for on-line inquiry access and for consolidated mailings based on the first ten-digits of the Medicaid ID number.

3. The system shall be able to identify newborns from the date of birth, submit the proper eligibility form to the State, and link the newborn record to the NJ FamilyCare/Medicaid eligibility and enrollment data when these data are received back from the State.

4.

The system shall capture and maintain all of the data elements provided by the Department on the weekly update files.

Exhibit 10.6.9

2.

Generation of correspondence to enrollees based on variable criteria., including PCP and demographic information.

3.2.3 CONTRACTOR ENROLLMENT VERIFICATION

A. Electronic Verification System. The contractor shall provide a system that supports the electronic verification of contractor enrollment to network providers via the telephone 24 hours a day and 365 days a year or on a schedule approved by the State. This capability should require the enrollee’s contractor Identification Number, the Medicaid/NJ FamilyCare Identification Number, or the Social Security Number. The system should provide information on the enrollee’s current PCP as well as the enrollment information.

B. Telephone Enrollment Inquiry. The contractor shall provide telephone operator personnel (both member services and provider services) to verify contractor enrollment during normal business hours. The contractor’s telephone operator personnel should have the capability to electronically verify contractor enrollment based on a variety of fields, including contractor Identification Number, the Medicaid/NJ FamilyCare Identification Number, Social Security Number, Enrollee Name, Date of Birth.

The contractor shall ensure that a recorded message is available to providers when enrollment capability is unavailable for any reason.

3.2.4 ENROLLEECOMPLAINT AND GRIEVANCE TRACKING SYSTEM

The contractor shall develop an electronic system to capture and track the content and resolution of enrollee complains or grievances.

A. Data Requirements. The system shall capture, at a minimum, the enrollee, the reason for the complaint or grievance, the date the complaint or grievance was reported, the operator who talked to the enrollee, the explanation of the resolution, the date the complaint or grievance was resolved, the person who resolved the complaint or grievance, referrals to other departments, and comments including general information and/or observations. See Article 5.15.

3.2.5 ENROLLEE REPORTING

The contractor shall produce all of the reports according to the timeframes and specifications outlined in Section A of the Appendices.

Exhibit 10.6.9

The contractor shall provide the State with a monthly file of enrollees (see section A.3.1 of the Appendices). The State’s fiscal agent will reconcile this file with the State’s Recipient File. The contractor shall provide for reconciling any differences and taking the appropriate corrective action.

3.3 PROVIDER SERVICES

The contractor’s System shall collect, process, and maintain current and historical data on program providers. This information shall be accessible to all parts of the MCMIS for editing and reporting.

3.3.1 PROVIDER INFORMATION AND PROCESSING REQUIREMENTS

A. Provider Data. The contractor shall maintain individual and group provider network information with basic demographics, EIN or tax identification number, professional credentials, license and/or certification numbers and dates, sites, risk arrangements (i.e., individual and group risk pools), services provided, payment methodology and/or reimbursement schedules, group/individual provider relationships, facility linkages, number of grievances and/or complaints.

For PCPs, the contractor shall maintain identification as traditional or safety net provider, specialties, enrollees with beginning and ending effective dates, capacity, emergency arrangements or contact, other limitations or restrictions, languages spoken, address, office hours, disability access. See Articles 4.8 and 5.

The contractor shall maintain provider history files and provide for easy data retrieval. The system should maintain audit trails of key updates.

Providers should be identified with a unique number. The contractor shall be able to cross-reference it provider number with the provider’s EIN or tax number, the provider’s license number, UPIN, Medicaid provider number or Medicaid-assigned number, as provided by the State in response to the contractor’s monthly Provider Network submission, and Medicare provider number where applicable. The contractor shall comply with the HIPAA requirements for provider identification.

B. Updates. The contractor shall apply updates to the provider file daily.

Exhibit 10.6.9

C. Complaint Tracking System. The system shall provide for the capabilities to track and report provider complaints as specified in Article 6.5. The contractor shall provide detail reports identifying open complaints and summary statistics by provider on the types of complaints, resolution, and average time for resolution.

3.3.2 PROVIDER CREDENTIALING

A. Credentialing. The contractor shall credential and re-credential each network provider as specified in Article 4.6.1. The system should provide a tracking and reporting system to support this process.

B. Review. The contractor shall be able to flag providers for review based on problems identified during credentialing, information received from the State, information received from CMS, complaints, and in-house utilization review results. Flagging providers should cause all claims to deny as appropriate.

3.3.3 PROVIDER/ENROLLEE LINKAGE

A. Enrollee Rosters. The contractor shall generate electronic (and/or hard copy if provider lacks capability to accept electronic files) enrollee rosters to its PCPs each month by the second business day of the month. The rosters shall indicate all enrollees that are assigned to the PCP and should provide the provider with basic demographic and enrollment information related to the enrollee.

B. Provider Capacity. The contractor’s system shall support the provider network requirements described in Article 4.8.

3.3.4 PROVIDER MONITORING

The contractor’s system shall support monitoring and tracking of provider/enrollee complaints, grievances and appeals from receipt to disposition. The system shall be able to produce provider reports for quality of medical and dental care analysis, flag and identify providers with restrictive conditions (e.g., fraud monitoring), and identify the confidentiality level of information (i.e., to manage who has access to the information).

3.3.5 REPORTING REQUIREMENTS

Exhibit 10.6.9

The contractor shall produce all of the reports identified in Section A of the Appendices. In addition, the system shall provide ongoing and periodic reports to monitor provider activity, support provider contracting, and provide administrative and management information as required for the contractor to effectively operate.

3.4 CLAIMS/ENCOUNTER PROCESSING

The system shall capture and adjudicate all claims and encounters submitted by providers. The major function of this module (s) include enrollee enrollment verification, provider enrollment verification, claims and encounter edits, benefit determination, pricing, medical review and claims adjudication, and claims payment. Once claims and encounters are processed, the system shall maintain the claims/encounter history file that supports the State’s encounter reporting requirements as well as all of the utilization management and quality assurance functions and other reporting requirements of the contractor.

3. 5 GENERAL REQUIREMENTS

The contractor shall have an automated claims and encounter processing system that will support the requirements of this contract and ensure the accurate and timely processing of claims and encounters. The contractor shall offer its providers an electronic payment option.

Exhibit 10.6.9

4. Contested Claims and Encounters

5. Aged Claims and encounters

6. Checks and EOB(s)

7. Lag Factors and IBNR

B. The contractor shall produce reports according to the timeframes and specification outlined in Section A of the Appendices.

3.4.4 REMITTANCE ADVICE AND CAPITATION LISTS

     The contractor shall provide federally qualified health centers with electronic remittance advices and electronic capitation lists of enrollees. In addition, the contractor shall provide copies of or a report of the data elements of the electronic remittance advices and capitation lists in Excel format to the DMAHS.

3.5 PRIOR AUTHORIZATION, REFERRAL AND UTILIZATION MANAGEMENT

The prior authorization/referral and utilization management functions shall be an integrated component of the MCMIS. It shall allow for effective management of delivery of care. It shall provide a sophisticated environment for managing the monitoring of both inpatient and outpatient care on a proactive basis.

3.5.1 FUNCTIONS AND CAPABILITIES

A. Prior Authorizations. The contractor shall provide an automated system that includes the following:

1. Enrollee eligibility, utilization, and case management information.

2. Edits to ensure enrollee is eligible, provider is eligible, and service is covered.

3. Predefined treatment criteria to aid in adjudicating the requests.

4. Notification to provider of approval or denial.

5. Notification to enrollees of any denials or cutbacks of service.

6. Interface with claims processing system for editing.

B. Referrals. The contractor shall provide an automated system that includes the following:

     1. Ability for providers to enter referral information directly, fax information to the contractor or call in on dedicated phone lines.

Exhibit 10.6.9

2. Interface with claims processing system for editing.

C. Utilization Management. The contractor should provide an automated system that includes the following:

1. Provides case tracking, notifies the case worker of outstanding actions.

2. Provide case history of all activity.

3. Provide online access to cases by enrollee and provider numbers.

Exhibit 10.6.9

D. The contractor shall acquire the capability to receive and transmit data in a secure manner electronically to and from the State’s data centers, which are operated by OIT. The standard data transfer software that OIT utilizes for electronic data exchange is Connect: Direct. Both mainframe and PC versions are available. A dedicated line is preferred, but at a minimum connectivity software can be used for the connection.

3.8.2 QUERY CAPABILITIES

The contractor’s MCMIS should have a sophisticated query tool with access to all major files for the users.

A. General. The system should provide a user-friendly, online query language to construct database queries to data available across all of the database(s), down to raw data elements. It should provide options to select query output to be displayed on-line, in a formatted, hard-copy report, or downloaded to the disk for PC-based analysis.

B. Unduplicated Counts. The system should provide the capability to execute queries that perform unduplicated counts (e.g., unduplicated count of original beneficiary ID number), duplicated counts (e.g., total number of services provided for a given aid category), or a combination of unduplicated and duplicated counts.

3.8.3 REPORTING CAPABILITIES

The contractor should provide reporting tools with its MCMIS that facilitate ad hoc, user, and special reporting. The MCMIS should provide flexible report formatting/editing capabilities that meet the contractor’s business requirements and support the Department’s information needs. For example, it should provide the ability to import, export and manipulate data files from spreadsheet, work processing and database management tools as well as the database(s) and should provide the capability to indicate header information, date and run time, and page numbers on reports. The system should provide multiple pre-defined report types and formats that are easily selected by users.

3.9 ENCOUNTER DATA REPORTING

A. The contractor shall collect, process, format, and submit electronic encounter data for all services delivered for which the contractor is responsible. The contractor shall capture all required encounter data elements using coding structures recognized by; the Department. The contractor

Exhibit 10.6.9

shall process the encounter data, integrating any manual or automated systems to validate the adjudicated encounter date. The contractor shall interface with any systems or modules within its organization to obtain the required encounter data elements. The contractor shall submit the encounter data to the Department’s fiscal agent electronically via diskette, tape or electronic transmission, according to specifications in the HIPPA Implementation and Companion Guides (HICG) Division’s Electronic Media Claims (EMC) Manual which will be distributed with regular updates may be periodically updated, and which are available at ▇▇▇.▇▇▇-▇▇▇.▇▇▇/▇▇▇▇▇ and ▇▇▇.▇▇▇▇▇▇.▇▇▇ respectively. The encounter data processing system shall have a data quality assurance plan to include timely data capture, accurate and complete encounter records, and internal data quality audit procedures. If DMAHS determines that changes are required, the contractor shall e given advance notice and time to make the change according to the extent and nature of the required change.

B. The contractor shall ensure that data received from providers is accurate and complete by:

1. Verifying the accuracy and timeliness of reported data;

2. Screening the data for completeness, logic, and consistency; and

3. Collecting service information in standardized formats to the extent feasible and appropriate.

C. Regardless of whether the contractor is considered a covered entity under HIPAA, the contractor shall use the HIPAA Transaction and Code Sets as the exclusive format for the electronic communication of health care claims and encounter data for data with dates of service on or after October 16, 2003.submitted on or after January 1, 2005, regardless of date of service. The contractor shall adhere to all HIPAA transaction set requirements as specified in the national HIPAA Implementation Guide and the New Jersey Medicaid HIPAA Companion Guide when submitting encounters.

3.9.1 REQUIRED ENCOUNTER DATA ELEMENTS

A. the contractor must report encounter data at least quarterly and no more frequently than monthly. The data shall be enrollee specific, listing all encounter data elements of the services provided. Encounter report files will be used to create a database that can be used in a manner similar to fee-for-service history files to analyze plan utilization, reimburse the contractor for supplemental payments, and calculate capitation premiums. DMAHS will edit the data to assure

Exhibit 10.6.9

consistency and readability. If data are not of an acceptable quality or submitted timely; the contractor will not be considered in compliance with this contract requirement until an acceptable file is submitted. All Types of Claims. The contractor shall capture all required encounter data elements for each of the eight claim types: Inpatient, Outpatient, Professional, Home Health, Transportation, Vision, Dental, and Pharmacy.

B. Data Elements. The required data elements shall be in compliance with HIPAA transaction set requirements (see 3.9.C) are provided in Section A.7.11. note that New Jersey specific Medicaid codes are required in some fields. Provides shall be identified using the provider’s EIN or tax-identification number. Inpatient hospital claims and encounters shall be combined into a single stay when the enrollee’s dates of services are consecutive.

C. Contractor Encounter. The contractor shall submit encounter data for claims and encounter received by the contractor. The contractor shall identify a capitated arrangement versus a “fee for service” arrangement for its network providers. For noncapitated arrangements, the contractor shall report the actual payment made to the provider for each encounter. For capitated arrangements the contractor may reports a zero payment for each encounter. However, a monthly “Capitation Summary Record” shall be required for each provider type, beneficiary capitation category, and service month combination. The specifications for the submission of monthly capitation summary records is further detailed in the EMC Manual issued by the Division.

3.9.2 SUBMISSION OF TEST ENCOUNTER DATA

A. Submitter ID. The contractor shall make application in order to obtain a Submitter Identification Number, according to the instructions listed in the EMC Manual issued by the Division. HIPAA Implementation and Companion Guides.

B. Test Requirement. The contractor shall be required to pass a testing phase for each of the eight encounter claim types before production encounter data will be accepted. The contractor shall pass the testing phase for all encounter claim type submissions within twelve (12) calendar weeks from the effective date of the contract. Contractors with prior contracting experience with DHS who have successfully submitted approved production data may be exempted at DHS’s option.

Exhibit 10.6.9

The contractor shall submit the test encounter data to the Department’s fiscal agent electronically, via diskette, tape, or electronic transmission according to the specifications of the Electronic Media Claims Manual issued by the Division HIPAA Implementation and Companion Guides.

The contractor shall be responsible for passing a two-phased test for each encounter claim type. The first phase requires that each submitted file follows the prescribed format that header and trailer records are present and correctly located within the file, and that the key fields are present. The second phase requires that the required data elements are present and properly valued. The contractor shall be responsible for passing a phased-in test process prior to submitting production encounter data. The details of the testing process and handling of errors are provided in the New Jersey Medicaid Companion Guide.

Following each submission and error report will be forwarded to the contractor identifying the file and record location of each error encountered for both testing phases. The contractor shall analyze the report, complete the necessary corrections, and re-submit the encounter data test file(s).

The contractor shall utilize production encounter data, systems, tables, and programs when processing encounter test files. The contractor shall submit error-free production data once testing has been approved for all of the encounter claims types.

3.9.3 SUBMISSION OF PRODUCTION ENCOUNTER DATA

A. Adjudicated Claims and Encounters. The contractor shall submit all adjudicated encounter data for all services provided for which the contractor is responsible. Adjudicated encounter data are defined as data from claims and encounters that the contractor has processed as paid or denied. The contractor is not responsible for submitting contested claims or encounters until final adjudication has been determined.

B. Schedule. Encounter data shall be submitted per the schedule established by the Department. Each Submission shall include encounter data that were adjudicated in the prior period and any adjustments for encounter data previously submitted.

Exhibit 10.6.9

C. Two-Phased Phased-in Process. Similar to testing, the contractor shall be responsible for passing a two phased-in test process for all production encounter data submitted. The details of production tests and handling of errors is are found in the New Jersey Medicaid Companion Guide. The first phase requires each submitted file follow the prescribed format, that header and trailer records are present and correctly located within the file and that the key fields are present. The second phase requires that the required data elements are present and properly valued.

D. Phase One Errors. If all or part of a production encounter file(s) rejects during phase one, an error report will be forwarded to the contractor identifying the file and record location of each error encountered. The contractor shall analyze the report, complete the necessary corrections, and re-submit the “rejected” encounter production data within forty-five (45) calendar days from the date the contractor receives the notice of error(S).

E. D. The contractor shall not be permitted to provide services under this contract nor shall the contractor receive capitation payment until it has passed the testing and production submission of encounter data.

E. Contractor Encounter. The contractor shall submit encounter data for claims and encounters received by the contractor. The contractor shall identify a capitated arrangement versus a “fee-for-service” arrangement for its network providers. For noncapitated arrangements, the contractor shall report the actual payment made to the provider for each encounter. For capitated arrangements, the contractor may report a zero payment for each encounter. However, a monthly “Capitation Summary Record” shall be required for each provider type beneficiary capitation category, and service month combination. The specifications for the submission of monthly capitation summary records is further detailed in the HIPAA Implementation and Companion Guides.

3.9.4 REMITTANCE ADVICE

     a. Remittance Advice File Processing Report. The Department’s fiscal agent shall produce a Remittance Advice File on a monthly basis that itemizes all processed encounters. The contractor shall be responsible for the acceptance and processing of a Remittance Advice (RA) File according to the specifications listed in the Division’s EMC Manual HIPAA Implementation and Companion Guides. The Remittance Advice File is produced on magnetic tape and contains all submitted

Exhibit 10.6.9

encounter data that passed phase one testing. The disposition (paid or denied) shall be reported for each encounter along with the “phase two” errors for those claims that the Division denied.

B. Reconciliation. The contractor shall be responsible for matching the encounters on the Remittance Advice File against the contractor’s data file(s). The contractor shall correct any encounters that denied improperly and/or any other discrepancies noted on the file. Corrections shall be resubmitted within thirty (30) calendar days from the date the contractor receives the Remittance Advice File.

All corrections to “Denied” encounter data, as reported on the Remittance Advice File, shall be resubmitted as “full record” adjustments, according to the requirements listed in the Division’s EMC Manual HIPAA Implementation and Companion Guides.

3.9.5 SUBCONTRACTS AND ENCOUNTER DATA REPORTING FUNCTION

A. Interfaces. All encounter data shall be submitted to the department directly by the contractor. DMAHS shall not accept any encounter data submissions or correspondence directly from any subcontractors, and DMAHS shall not forward any electronic media, reports or correspondence directly to a subcontractor. The contractor shall be required to receive all electronic fields and hardcopy material from the Department, or its appointed fiscal agent, and distribute them within its organization or to its subcontractors appropriately.

B. Communication. The contractor and its subcontractors shall be represented at all DMAHS meetings scheduled to discuss any issue related to the encounter function requirements.

3.9.6 FUTURE ELECTRONIC ENCOUNTER SUBMISSION REQUIREMENTS

At the present time, the Centers for Medicare and Medicaid Services (CMS) is pursuing a standardization of all electronic health care information, including encounter data. The contractor shall be responsible for completing and paying for any modifications required to submit encounter data electronically, according to the same specifications and timeframes outlined by CMS for the New Jersey MMIS.

Exhibit 10.6.9

with the contractor with respect to payment. Further, the contractor shall ensure that the cost to the enrollee is no greater than it would be if the services were furnished within the network.

4.1.1.G.4 Protecting Managed Care Enrollees Against Liability for Payment.

As a general rule, if a participating or non-participating provider renders a covered service to a managed are enrollee, the provider’s sole recourse for payment, other than collection of any authorized cost-sharing and/or third party liability, is the contractor, not the enrollee. A provider may not seek payment from, and may not institute or cause the initiation of collection proceedings or litigation against, an enrollee, an enrollee’s family member, any legal representative of the enrollee, or anyone else acting on the enrollee’s behalf unless subsections (a) through and including (f) or subsection (g) below apply:

     (a) (1) The service is not a covered service; or (2) the service is determined to be medically unnecessary before it is rendered; or (3) the provider does not participate in the program either generally or for that service.

     (b) The enrollee is informed in writing before the service is rendered that one or more of the conditions listed in subsection (a) above exist, and voluntarily agrees in writing before the service is rendered to pay for all or part of the provider’s charges; and

     (c) The service is not an emergency or related service covered by the provisions of 42 USC 1396u-2(bb)(2)(A)(ii), 42 CFR 438.114 and/or NJAC 10:74-9.1; and

     (d) The service is not a trauma service covered by the provisions of the NJAC 8:38-6.3(a)3.i; and

     (e) The protections afforded to enrollees under 42 USC 1396u-2(b)(6), 42 CFR438.106, NJAC 8:38-9.1(d)9, and/or NJAC 8:38-15.2(b)7.ii do not apply; and

     (f) The provider has received no program payments from either DMAHS or the contractor for the service; or

(g) the enrollee has been paid for the service by a health insurance company or other third party (as defined in NJSA 30:4D-3.m), and the enrollee has failed or refused to remit to the provider that portion of the third party’s payment to which the provider is entitled by law.

H. The contractor shall have policies and procedures on the use of enrollee self-referred services.

I. The contractor shall have policies and procedures on how it will provide for genetic testing and counseling.

Exhibit 10.6.9

11. Audiology

12. Inpatient Rehabilitation services

13. Podiatrist Services

14. Chiropractor Services

15. Optometrist Services

16. Optical Appliances

17. Hearing Aid Services

4.1.2.A..18 Home Health Agency Services — Not a contractor-covered benefit for the ABD population. All other services provided to any enrollee in the home, including but not limited to pharmacy (not applicable to the ABD population) and DME services, are the contractor’s fiscal and medical management responsibility.

	19.		Hospice Services — are covered in the community as well as in institutional settings. Room and board services are included only when services are delivered in an institutional (non-private residential) setting.
	20.		Durable Medical Equipment (DME)/Assistive Technology Devices in accordance with existing Medicaid regulations.
	21.		Medical Supplies
	22.		Prosthetics and Orthotics including certified shoe provider
	23.		Dental Services
	24.		Organ Transplants — includes donor and recipient costs. Exception: the contractor will not be responsible for transplant-related donor and recipient inpatient hospital costs for an individual placed on a transplant list while in the Medicaid FFS program prior to initial enrollment into the contractor’s plan.

Exhibit 10.6.9

	25.		Transportation Services for any contractor-covered service or non-contractor covered service including ambulance, mobile intensive care units (MICUs) and invalid coach (including lift equipped vehicles)
	26.		Post-acute Care

Exhibit 10.6.9

4.2.1.K.3. Late notification of Emergent Inpatient Hospital Admissions. If the contractor receives late notification from participating hospitals of emergent hospital admissions because of the participating hospital’s inability to identify the patient’s HMO due to extenuating circumstances, the contractor may require proof from the participating hospital that it could not identify the patient through eligibility verification or because of the medical condition or the patient. The following procedure shall be followed:

     a. If the contractor receives notification of an emergent inpatient hospital admission from its participating hospital later than one business day, but no later than seven (7) business days following the emergent inpatient admission at the participating hospital due to the hospital’s inability to identify the patient as the contractor’s member, the contractor shall review the hospital stay for medical necessity for each inpatient day. The review will utilize the usual and customary concurrent review process agreed to by both parties. The contractor shall complete its medical necessity review within seven (7) business days of receiving all of the requested information from the participating hospital.

     b. Participating hospitals shall notify the contractor within one (1) business day once they have identified the patient’s HMO.

     c. If the contractor receives the notification from the participating hospital later than seven (7 business days following an emergent inpatient admission at the participating hospital due to the hospital’s inability to identify the patient as the contractor’s member, the contractor shall review the case for medical necessity for each inpatient day. With these cases, the contractor may reserve the right to conduct a more extensive review than the usual and customary concurrent review process. The contractor shall also complete its review within seven (7) business days of receiving all of the requested information from the participating hospital.

     d. If the contractor determines that a participating hospital routinely notifies the contractor of a member admission beyond one business day, the contractor will work with the participating hospital to resolve the issues and re-educate the staff of the notice of the admission requirements and member eligibility verification procedures.

L. The contractor shall establish and maintain policies and procedures for emergency dental services for all enrollees.

     1. Within the contractor’s Enrollment/Service Area, the contractor will ensure that:

Exhibit 10.6.9

2. NJ FamilyCare Plans B and C. For children eligible solely through NJ FamilyCare Plans B and C, coverage includes all preventative screening and diagnostic services, medical examinations, immunizations, dental, vision, lead screening and hearing services. Includes only those treatment services identified through the examination that are included under the contractor’s benefit package or specified services through the FFS program. Other services identified through an EPSDT examination that are not included in the New Jersey Care 2000+ covered benefits package are not covered.

	3.		Enrollee Notification. The contractor shall provide written notification to its enrollees under twenty-one (21) years of age when appropriate periodic assessments or needed services are due and must coordinate appointments for care.
	4.		Missed Appointments. The contractor shall implement policies and procedures and shall monitor its providers to provide follow up on missed appointments and referrals from problems identified through the EPSDT exams. Reasonable outreach shall be documented and must consist of: mailers, certified mail as necessary; use of MEDM system provided by the State; and contact with the Medical Assistance Customer Center (MACC), DDD, or DYFS regional offices in the case of DYFS enrollees to confirm addresses and/or to request assistance in locating an enrollee.
	5.		PCP Notification. The contractor shall provide each PCP, on a calendar quarter basis, as list of the PCP’s enrollees who have not had an encounter during the past year and/or who have not complied with the EPSDT periodicity and immunization schedules for children. Primary care sites/PCPs and/or the contractor shall be required to contact these enrollees to arrange an appointment. Documentation of the outreach efforts and responses is required.

4.2.6.A.6. Reporting Standards. The contractor shall submit quarterly reports, hard copy and on diskette, of the EPSDT services. See Section A.7.16 of the Appendices (Table 14).

B. Section 1905(r) of the Social Security Act (42 USC § 1396(d) and federal regulation 42 C.F.R. § 441.50 et. Seq. requires EPSDT services to include:

1. EPSDT Services which include:

     a. A comprehensive health and developmental history including assessments of both physical and mental health development and the provision of all diagnostic and treatment

Exhibit 10.6.9

services that are medically necessary to correct or ameliorate a physical or mental condition identified during a screening visit. The contractor shall have procedures in place for referral to the State or its agent for non-covered mental health/substance abuse services.

b. A comprehensive unclothed physical examination including:

	•		Vision and hearing screening;
	•		Dental inspection; and
	•		Nutritional assessment

4.2.6.B.1.c. Appropriate immunizations according to age, health history and the schedule established by the Advisory Committee on Immunization Practices (ACIP) for pediatric vaccines (See Section B.4.3 of the Appendices). Contractor and its providers must adjust for periodic changes in recommended types and schedule of vaccines. Immunizations must be reviewed at each screening examination as well as during acute care visits and necessary immunizations must be administered when not contraindicated. Deferral of administration of a vaccine for any reason must be documented.

d. Appropriate laboratory tests: A recommended sequence of screening laboratory examinations must be provided by the contractor. The following list of screening tests is not all inclusive:

	•		Hemoglobin/hematocrit/EP
	•		Urinalysis
	•		Tuberculin test — intradermal, administered annually and when medically indicated
	•		Lead screening using blood lead level determinations must be done for every Medicaid-eligible and NJ FamilyCare child:

	o		between nine (9) months and eighteen (18) months, preferably at twelve (12) months of age
	o		at 18-26 months, preferably at twenty-four (24) months of age
	o		test any child between twenty-seven (27) to seventy-two (72) months of age not previously tested

Exhibit 10.6.9

•

Additional laboratory tests may be appropriate and medically; indicated (e.g., for ova an parasites) and shall be obtained as necessary.

e. Health education/anticipatory guidance.

f. Referral for further diagnosis and treatment or follow-up of all abnormalities which are treatable/correctable or require maintenance therapy uncovered or suspected (referral may be to

Exhibit 10.6.9

ii. The contractor shall implement plans for corrective action with those identified PCPs that describe interventions to be taken to identify and correct deficiencies and impediments to the screening and how the effectiveness of its interventions will be measured.

e. On a quarterly basis, the contractor shall submit to DMAHS a report of all lead-burdened children who are receiving treatment and case management services.

4.2.6.B.7.f. Lead Case Management Program. The contractor shall establish a Lead Case Management Program (LCMP) and have written policies and procedures for the enrollment of children with blood lead levels ³10 µg/dl and other contractor enrollees who are members of the same household and who are between six months and six years of age, into the contractor’s LCMP.

i. Lead Case Management shall consist of, at a minimum:

1) Follow-up of a child in need of lead screening, or who has been identified with an elevated blood lead level ³10 µg/dl. At minimum follow-up shall include:

     A) For a child with an elevated blood lead level ³10 µg/dl, the Plan’s LCM shall ascertain if the blood lead level has been confirmed by a venous blood determination. In the absence of confirmatory test results, the LCM will arrange for a test.

     B) For a child with a confirmed blood (venous) lead level of ³10 µg/dl, the contractor’s LCM shall notify and provide to the local health department the child’s name, primary health provider’s name, the confirmed blood lead level, and any other pertinent information.

2) Education of the family about all aspects of lead hazard and toxicity. Materials shall explain the sources of lead exposure, the consequences of elevated blood levels, preventative measures, including housekeeping hygiene, and appropriate nutrition. The reasons why it is necessary to follow a prescribed medical regimen shall also be explained.

3) Communication among all interested parties.

4) Development of a written case management plan with the PCP and the child’s family and other interested parties. The case management plan shall be reviewed and updated on an ongoing basis.

Exhibit 10.6.9

5) Coordination of the various aspects of the affected child’s care, e.g., WIC, support groups, and community resources, and

6) Aggressively pursuing non-compliance with follow-up tests and appointments, and document these activities in the LCMP.

4.2.6.B.7.f.ii. Active case management may be discontinued if one of the following criteria has been met:

1) The child has one confirmed blood lead level <10 µg/dl drawn and all other children under the age of six years living in the household who are also contractor enrollees and who have been tested and their blood levels are <10 µg/dl, and the sources of lead have been identified and reduced, or

2) The family has been permanently relocated to a lead-safe house, or

3) The parent/guardian has given a written refusal of service, or

4) The LCM is unable to locate the child after a minimum of three documented attempts, using the assistance of County Board of Social Services, and the LHD. The child’s PCP will be notified in writing.

4.2.7 IMMUNIZATIONS

A. General. The contractor shall ensure that its providers furnish immunizations to its enrollees in accordance with the most current recommendations for vaccines and periodicity schedule of the Advisory Committee on Immunization Practices (ACIP) and any subsequent revision to the schedule as formally recommended by the ACIP, whether or not included as a contract amendment. To the extent possible, the State will provide copies of updated schedules and vaccine recommendations.

Exhibit 10.6.9

Need for an examination based on a Head Start referral if the enrollee has had an age-appropriate EPSDT examination (for infants) or an EPSDT examination (for children two (2) to five (5) years old) within six (6) months of the referral date.

9. Policies and Procedures for Head Start’s role in prevention activities or programs developed by the contractor.

B. The contractor shall evaluate referred Head Start patients to determine the need for treatment/therapies for problems identified by staff of those programs. The contractor/PCP shall be responsible for providing treatment and follow-up information for medically necessary care.

C. The contractor shall review referrals and provide appointments in accordance with Article 5.12. Denials of service requests or reduction in level of service only after an evaluation is completed, shall be in writing, following the requirements in Article 4.6.4.

SCHOOL-BASED YOUTH PROGRAMS

A. The contractor shall demonstrate to DMAHS that is has established a working linkage with school-based youth services programs (SBYSP) that meet credentialing and scope of service requirements for services offered by these programs which are covered MCE services. (See section B.4.6 of the Appendixees fro a list of SBYSPs).

1. SBYSP service provision must meet MCE contract requirements, e.g., twenty-four (24)-hour coverage.

2. SBYSP employees must meet credentialing requirements.

B. Such working linkages shall include, at minimum, and exchange of information on the following:

1. Policies and procedures for referrals for routine, urgent and emergent care, and standing referrals.

2. Policies and procedures for scheduling appointments for routine and urgent care.

3. Policies and procedures for the exchange of information of SBYSP participants who are contractor enrollees.

Exhibit 10.6.9

4. Policies and procedures for follow-up and assuring the provision of health care services.

5. Policies and procedures for appealing denials of service and/or reductions in the level of service.

Exhibit 10.6.9

3. Care management systems to ensure all required services, as identified through a Complex Needs Assessment, are furnished on a timely basis, and that communication occurs between participating and nonparticipating providers (to the extent the latter are used). Articles 4.5.4 and 4.6.5 contain additional information on care managements.

4. Policies and procedures to allow for the continuation of existing relationships with non-participating providers, when appropriate providers are not available within network or it is otherwise considered by the contractor to be in the best medical interest of the enrollee with special needs. Articles 4.5.2D and 4.8.7G contain more specific standards for use of non-participating providers.

5. Methods to assure that access to all contractor-covered services, including transportation, is available for enrollees with special needs whose disabilities substantially impede activities of daily living. The contractor shall reasonably accommodate enrollees with disabilities and shall ensure that physical and communication barriers do not prohibit enrollees with disabilities from obtaining services from the contractor.

6. Services for enrollees with special needs must be provided in a manner responsive to the nature of a person’s disability/specific health care need and include adequate time for the provision of the service.

4.5.2.B. The contractor shall ensure that any new enrollee identified (either by the information on the Medical Information form Plan Selection Form at the time of enrollment or by contractor providers after enrollment) as having complex/chronic conditions receives immediate transition planning. The planning shall be completed within a timeframe appropriate to the enrollee’s condition, but in no case later than ten (10) business days from the effective date of enrollment when the Medical Information form Plan Selection Form has an indication of special health care needs or within thirty (30) days after special conditions are identified by a provider. This transition planning shall not constitute the IHCP described in Sections 4.5.4 and 4.6.5. Transition planning shall provide for a brief, interim plan to ensure uninterrupted services until a more detailed plan of care is developed. The transition planning process includes, but is not limited to:

1. Review of existing care plans.

Exhibit 10.6.9

2. Preparation of a transition plan that ensures continuous care during the transfer into the contractor’s network.

3. If durable medical equipment has been ordered prior to enrollment but not received by the time of enrollment, the contractor must coordinate and follow-through to ensure that the enrollee receives necessary equipment.

C. Outreach and Enrollment Staff. The contractor shall have outreach and enrollment staff who are trained to work with enrollees with special needs, are

Exhibit 10.6.9

4.5.4.B. Complex Needs Assessment. For enrollees with special needs, the contractor shall perform a Complex Needs Assessment no later than forty-five (45) days (or earlier, if urgent) from initial enrollment if special needs are indicated on the Medical Information form Plan Selection Form or from the point of identification of special needs. See 4.6.5 for a description of the CNA. Additional time will be permitted if the contractor demonstrates a good faith level of effort in developing the CNA, and the contractor has in place a continuum of care while assessment is being completed.

C. Experience and Caseload. Care managers for enrollees who require a higher level of care management will have the same role and responsibilities as the care manager for the lower intensity care management and additionally will address the complex intensive needs of the enrollee identified as being at “high risk” of adverse medical outcomes absent active intervention by the contractor. For example, a visually-impaired, insulin-dependent diabetic who requires frequent glucose monitoring, nutritional guidance, vision checks, and assistance in coordination with visits with multiple providers, therapeutic regimen, etc. The contractor shall provide intensive acute care services to treat individual with multiple complex conditions. The number of medical and social services required by an enrollee in this level of care management will generally be greater, thus the number of linkages to be created, maintained, and monitored, including the promotion of communication among providers and the consumer and of continuity of care, will be greater. The contractor shall provide these enrollees greater assistance with scheduling appointments/visits. The intensity and frequency of interaction with the enrollee and other members of the treatment team will also be greater. The care manager shall contact the enrollee bi-weekly or as needed.

1. At a minimum, the care manager for this level of care management shall include, but is not limited to, individual who hold current RN licenses with at least three (3) years experience serving enrollees with special needs or a graduate degree in social work with at least two (2) years experience serving enrollees with special needs.

2. The contractor shall ensure that the care manager’s caseload is adjusted, as needed, to accommodate the work and level of effort needed to meet the needs of the entire case mix of assigned enrollees including those determined to be high risk:

3. The contractor should include care managers with experience working with pediatric as well as adult enrollees with special needs.

Exhibit 10.6.9

D. IHCPs. The contractor through its care manager shall ensure that an Individual Health care Plan (IHCP) is developed and implemented as soon as possible, according to the circumstances of the enrollee. The contractor shall ensure the full participation and consent of the enrollee or, where applicable, authorized person and participation of the enrollee’s PCP, consultation with any specialists.

Exhibit 10.6.9

j. The review and approval of studies and responses to DMAHS concerning QM matters.

3. Enrollee Rights and Responsibilities. Shall include the right to the Medicaid Fair Hearing Process for Medicaid enrollees.

4. Medical Record standards shall address both Medical and Dental records. Records shall also contain notation of any cultural/linguistic needs of the enrollee.

5. Provider Credentialing. Before any provider may become part of the contractor’s network, that provider shall be credentialed by the contractor. The contractor must comply with N.J.A.C. 8:38C-1 et seq. and Standard IX of NJ modified QARI/QISMC (Section B.4.14 of the Appendices). Additionally, the contractor’s credentialing procedures shall include verification that providers and subcontractors have not been suspended, debarred, disqualified, terminated or otherwise excluded from Medicaid, Medicare, or any other federal or state health care program. The contractor shall obtain federal and State lists of suspended/debarred providers from the appropriate agencies.

6. Institutional and Agency Provider Credentialing. The contractor shall have written policies and procedures for the initial quality assessment of institutional and agency providers with which it intends to contract. At a minimum, such procedures shall include confirmation that a provider has been reviewed and approved by a recognized accrediting body and is in good standing with State and federal regulatory bodies. If a provider has not been approved by a recognized accrediting body, the contractor shall develop and implement standards of participation. For home health agency and hospice agency providers, the contractor shall verify that the providers are licensed and meet Medicare certification participation requirements.

7. Delegation/subcontracting of QAPI activities shall not relieve the contractor of its obligation to perform all QAPI functions. The contractor shall submit a written request and a plan for active oversight of the QAPI activities to DMAHS for review and approval prior to subcontracting/delegating any QAPI responsibilities.

4.6.1.C.8. Dental Service Coordinator. The contractor shall have on staff a Dental Service Coordinator who shall be responsible for:

Exhibit 10.6.9

a. Coordinating of all dental activities of the contractor;

b. Monitoring activities to review the performance of dental providers in their provision of health care to enrollees.

c. Responses to DMAHS concerning dental related QM matters; and

d. If the contractor contracts with a dental subcontractor, the contractor’s Dental Services Coordinator shall monitor vendor performance; provide direction to the dental subcontractor; ensure that decisions are made in a clinically appropriate and timely manner; and address dental issues at the contractor level.

4.6.2 QAPI ACTIVITIES

The contractor shall carry out the activities described in its QAPI. The contractor shall develop and submit to DMAHS annually an annual work plan of expected accomplishments which includes a schedule of clinical standards to be developed, medical care evaluations to be completed, and other key quality assurance activities to be completed. The contractor shall also prepare and submit to DMAHS an annual report on quality assurance activities which demonstrate the contractor’s accomplishments, compliance and/or deficiencies in meeting its previous year’s work plan and should include studies undertaken, subsequent actions, and aggregate data on utilization and clinical quality of medical care rendered.

The contractor’s quality assurance activities shall include, at a minimum:

A. Guidelines. The contractor shall develop guidelines that meet the requirements of 42 CFR 438 for the management of selected diagnoses and basic health maintenance, and shall distribute all standards, protocols, and guidelines to all providers and upon request to enrollees.

B. Treatment Protocols. The contractor may use treatment protocols, however, such protocols shall allow for adjustments based on the enrollee’s medical condition and contributing family and social factors.

C. Monitoring. The contractor shall have procedures for monitoring the quality and adequacy of medical care including: 1) assessing use of the distributed guidelines and 2) assessing possible under-treatment/under-utilization of services.

D. Focused Evaluations. The contractor shall have procedures for focused medical care evaluations to be employed when indicators suggest that quality may need to be studied. The contractor shall also have procedures for conducting problem-oriented clinical studies of individual care.

Exhibit 10.6.9

E. Follow-up. The contractor shall have procedures for prompt follow-up of reported problems and complaints involving quality care issues.

F. Reserved.

Exhibit 10.6.9

appropriate use of new medical technologies or new applications of established technologies including medical procedures, drugs, devices, assistive technology devices, and DME.

N. Informed Consent. The contractor is required and shall require all participating providers to comply with the informed consent forms and procedures for hysterectomy and sterilization as specified in 42 C.F.R. Part 441, Sub-part B, and shall include the annual audit for such compliance in its quality assurance reviews of participating providers. Copies of the forms are included in Section B.4.15 of the Appendices.

O. Continuity of Care. The contractor’s Quality Management Plan shall include a continuity of care system including a mechanism for tracking issues over time with an emphasis on improving health outcomes, as well as preventive services and maintenance of function for enrollees with special needs.

4.6.2.P. HEDIS. The contractor shall submit annually, on a date specified by the State, HEDIS 3.0 data or more updated version, aggregate population data as well as, if available, the contractor’s commercial and Medicare enrollment HEDIS data for its aggregate, enrolled commercial and Medicare population in the State or region (if these data are collected and reported to DHSS, a copy of the report should be submitted also to DMAHS) the following clinical indicator measures:

HEDIS		Report Period
Reporting Set Measures		by Contract Year
*Childhood Immunization Status		Annually
*Adolescent Immunization Status		Annually
*Well-Child visits in first 15 months of life		Annually
* Well-Child visits in the 3rd, 4th, 5th, and 6th year of life		annually
Adolescent Well-Care Visits		annually
*Prenatal and Postpartum care		annually
Breast Cancer Screening		annually
Cervical Cancer Screening		annually
*Use of Appropriate Medication for People with Asthma		annually
Comprehensive Diabetes Care		annually

Exhibit 10.6.9

Childhood & Adolescent Immunization *NOTE: HEDIS data for NJ FamilyCare enrollees up to the age of 19 years must be reported separately.

Q. Quality Improvement Projects (QIPs). The contractor shall participate in QIPs defined annually by the State with input from the contractor. The State will, with input from the contractor and possibly other MCEs define measurable improvement goals and QIP-specific measures which shall serve as the focus for each QIP. The contractor shall be responsible for designing and implementing strategies for achieving each QIP’s objectives. At the beginning of each contract year the contractor shall present a plan for designing and implementing such strategies, which shall receive approval from the State prior to implementation.

Exhibit 10.6.9

2. Clinical performance measures on outcomes of care;

3. Maintenance and preventive services;

4. Enrollee experience and perceptions of service delivery; and

5. Access.

For MH/SA services provided to enrollees who are clients of DDD the contractor shall report MH/SA utilization data to its providers.

W. Member Satisfaction. The State will assess member satisfaction of contractor services by conducting surveys employing the Consumer Assessments of Health Plans Study (CAHPS) survey, or another survey instrument specified by the State. The survey shall be stratified to capture statistically significant results for all categories of New Jersey Care 2000+ enrollees including AFDC/TANF, DYFS, SSI and New Jersey Care Aged, Blind and Disabled, NJ FamilyCare, pregnant and parenting women, and racial and linguistic minorities. Sample size, sample selection, and implementation methodology shall be determined by the State, with contractor input, to assure comparability of results across State contractors.

The contractor shall fully cooperate with the State and the independent survey administrator such that final, analyzed survey results shall be available from the survey administrator to the State, in a format approved by the State, by a date specified by the State of each contract year. Within sixty (60) days of receipt of the final analyzed survey results sent to the contractor, it shall identify leading sources of enrollee dissatisfaction, specify additional measurement or intervention efforts developed to address enrollee dissatisfaction, and a timeline, subject to State approval, indicating when such activities will be completed. A status report on the additional measurement or intervention efforts shall be submitted to the State by a date specified by DMAHS. The contractor shall respond to and submit a corrective action to address and correct problems and deficiencies found through the survey.

If the contractor conducts a member satisfaction survey of its own, it shall send to DMAHS the results of the survey.

4.6.2.X. Enrollee Outreach and Education Assessment. The State will conduct a needs assessment to determine the areas of service provision that require additional enrollee outreach and education. The assessment will evaluate member understanding of the managed care system, ability to access

Exhibit 10.6.9

appropriate and needed services, effectiveness of enrollee communication methods, and areas of difficulty for enrollees. The assessment will comprise various informal enrollee surveys conducted by the State throughout the year. The surveys may be conducted in person, by telephone, mail or other means, and will ascertain information on areas that require additional enrollee outreach and education by the State and/or the contractor. The contractor shall cooperate with the State in identifying target groups to survey, topics and materials to survey, and opportunities for revised and/or additional enrollee outreach and education activities as a result of the surveys.

The State shall not divulge the names or other identifying information of those surveyed to the contractor or any other party except in the case where an enrollee gives permission to the State to be contacted for assistance with a stated question or problem. The State will annually summarize and provide to the contractor, its findings and recommendations for future enrollee outreach and education activities.

X. Focus Groups. The State will annually conduct four focus groups with enrolled populations identified by the State and communicated in writing to the contractor. Objectives for the focus groups will be collaboratively developed by the State and the contractor. For the first contract year, two focus groups each will be conducted with enrollees who have communication affecting disorders and with enrollees who are elderly.

Focus groups results will be reported by the State. The contractor shall identify opportunities for improvement identified through the focus groups, specify additional measurement or intervention efforts developed to address the opportunities for improvement, and a timeline, subject to State approval., indicating when such activities will be completed. A status report on the additional measurement or intervention efforts shall be submitted annually to the State by a date specified by DMAHS.

Y. ERO. Other “areas of concern” shall be monitored through the external review process. The External Review Organization (ERO) shall, in its monitoring activities, validate the contractor’s protocols, sampling, and review methodologies.

Z. Community /Health Education Advisory Committee. The contractor shall establish and maintain a community advisory committee, consisting of persons being served by the contractor, including

Exhibit 10.6.9

enrollees or authorized persons, individual and providers with knowledge of and experience with serving elderly people or people with disabilities; and representatives from community agencies that do not provide contractor-covered services but are important to the health and well-being of members. The committee shall meet at least quarterly and its input and recommendations shall be employed to inform and direct contractor quality management activities and policy and operations changes. The DMAHS shall conduct on-site review of the membership of this committee, as well as the committee’s activities throughout the year.

AA. Provider Advisory Committee. The contractor shall establish and maintain a provider advisory committee, consisting of providers contracting with the contractor to serve enrollees. At least two providers on the committee shall maintain practices that predominantly serve Medicaid beneficiaries and other indigent populations. In addition to at least one other practicing provider on the committee who has experience and expertise in serving enrollees with special needs. The committee shall meet at least quarterly and its input and recommendations shall be employed to inform and direct contractor quality management activities and policy and operations changes. The DMAHS shall conduct on-site review of the membership of this committee, as well as the committee’s activities throughout the year.

4.6.2.AA.1. The contractor shall have a Dental Affairs Advisory subcommittee to give participating dental providers the opportunity to provide input to the HMO in improving dental screening performance rates and quality of care.

4.6.3 REFERRAL SYSTEMS

A. The contractor shall have a system whereby enrollees needing specialty medical and dental care will be referred timely and appropriately. The system shall address authorization for specific services with specific limits or authorization of treatment and management of a case when medically indicated (e.g., treatment of a terminally ill cancer patient requiring significant specialist care). The contractor shall maintain and submit a flow chart accurately describing the contractor’s referral system, including the title of the person(s) responsible for approving referrals. The following items shall be contained within the referral system:

1. Procedures for recording and tracking each authorized referral.

2. Documentation and assurance of completion of referrals.

Exhibit 10.6.9

3. Policies and procedures for identifying and rescheduling broken referral appointments with the providers and/or contractor as appropriate (e.g., EPSDT services).

4. Policies and procedures for accepting, resolving, and responding to verbal and written enrollee requests for referrals made to the PCP and/or contractor as appropriate. Such requests shall be logged and documented. Requests that cannot be decided upon immediately shall be responded to in writing no later than five (5) business days from the date of receipt of the request (with a call made to the enrollee on final disposition) and postmarked the next day.

5. Policies and procedure for proper notification of the enrollee and where applicable, authorized person, the enrollee’s provider, and the enrollee’s care manager, including notice of right to appeal and/or right to request a second opinion when services are denied.

6. A referral form which can be given to the enrollee or, where applicable, an authorized person to take a specialist.

7. Referral form mailed, faxed, or sent by electronic means directly to the referral provider.

Exhibit 10.6.9

d. The action taken or intended to be taken by the contractor on the request for prior authorization and the reason for such action including clinical rationale and the underlying contractual basis or Medicaid authority;

e. The name and address of the contractor;

f. Notice of internal (contractor) appeal rights and instructions on how to initiate such appeal;

g. Notice of the availability, upon request, of the clinical review criteria relied upon to make the determination;

h. the notice to the enrollee shall inform the enrollee that he or she may file an appeal concerning the contractor’s action using the contractor’s appeal procedure prior to or concurrent with the initiation of the State hearing process.

i. The contractor shall notify enrollees, and/or authorized persons within the time frames set forth in this contract and in 42 CFR 438.404(c);

j. The enrollee’s right to have benefits continue (see Article 4.6.4C) pending resolution of the appeal and how to request that benefits be continued.

9. In no instance shall the contractor apply prior authorization requirements and utilization controls that effectively withhold or limit medically necessary services, or establish prior authorization requirements and utilization controls that would result in a reduced scope of benefits for any enrollee.

4.6.4C. Appeal Process of UM Determinations. The contractor shall have policies and procedures for the appeal of utilization management determinations and similar determinations. In the case of an enrollee who was receiving a covered service (from the contractor, another contractor, or the Medicaid Fee-for-Service program) prior to the determination, the contractor shall continue to provide the same level of service while the determination is in appeal. However, the contractor may require the enrollee to receive the service from within the contractor’s provider network, if equivalent care can be provided within network.

1. The contractor shall provide that an enrollee, and any provider acting on behalf of the enrollee with the enrollee’s consent (enrollee’s consent shall not be require in the case of a deceased patient, or when an enrollee has relocated and cannot be found), may appeal any UM decision resulting in a denial, termination, or other limitation in the coverage of and access to health care services in accordance with this contract and as defined in C.2.

Exhibit 10.6.9

4.6.4.G.6. Continuation of benefits. The MCO shall continue the enrollee’s benefits if —

a. the enrollee or the provider files the appeal timely;

b. the appeal involves the termination suspension, or reduction of a previously authorized course of treatment;

c. The services were ordered by an authorized provider (i.e. a network provider); and

d. the original period covered by the original authorization has not expired, unless inadequate notice was given to allow an enrollee a timely appeal.

7. Duration of continued or reinstated benefits. The contractor shall continue the enrollee’s benefits while an appeal is pending. The benefits must be continued until one of the following occurs:

a. the enrollee withdraws the appeal,

b. Ten days pass after the contractor mails the notice, providing the resolution of the appeal against the enrollee, unless the enrollee, within the 10-day timeframe has requested a State fair hearing with continuation of benefits until a State fair hearing decision is reached.

c. A State fair hearing Office issues a hearing decision adverse to the enrollee.

d. The time period or service limits of a previously authorized service has been met.

8. Effectuation of reversed appeal resolutions.

a. Services not furnished while the appeal is pending. If the contractor or the State fair hearing officer reverses a decision to deny, limit or delay services that were not furnished while the appeal was pending, the contractor must authorize or provide the disputed services promptly, and as expeditiously as the enrollee’s health condition requires.

b. Services furnished while the appeal is pending. If the contractor or the State fair hearing officer reverses a decision to deny authorization of services, and the enrollee received the disputed services while the appeal was pending, the contractor must pay for those services, in accordance with this contract.

9. Expedited Resolution of Appeals. The contractor shall establish and maintain an expedited review process for appeals when the contractor determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee’s behalf or supporting the enrollee’s request) that taking the time for a standard resolution could seriously jeopardize the enrollee’s life or health or

Exhibit 10.6.9

ability to attain, maintain or regain maximum function.

Exhibit 10.6.9

C. The contractor hereby agrees to medical audits in accordance with the protocols for care specified in this contract, in accordance with medical community standards for care, and of the quality of car provided all enrollees, as may be required by appropriate regulatory agencies.

D. The contractor shall cooperate with DMAHS in carrying out the provisions of applicable statutes, regulations, and guidelines affecting the administration of this contract.

E. The contractor shall distribute to all subcontractors providing services to enrollees, informational materials approved by DMAHS that outlines the nature, scope, and requirements of this contract.

F. The contractor, with the prior written approval of DMAHS, shall print and distribute reporting forms and instructions, as necessary whenever such forms are required by this contract.

G. The contractor shall make available to DMAHS copies of all standards, protocols, manuals and other documents used to arrive at decisions on the provision of care to its DMAHS enrollees.

H. The contractor shall use appropriate clinicians to evaluate the clinical data, and must use multi-disciplinary teams to analyze and address systems issues.

I. contractor shall develop an incentive system for providers to assure submission of encounter data. At a minimum, the system shall include:

     1. Mandatory provider profiling that includes complete and timely submissions of encounter data. Contractor shall set specific requirements for profile elements based on data from encounter submissions.

     2. Contractor shall set up data submission requirements based on encounter data elements for which compliance performance will be both rewarded and/or sanctioned.

J. The contractor shall include in its quality management system reviews/audits which focus on the special dental needs of enrollees with developmental disabilities. Using encounter data reflecting the utilization of dental services and other data sources, the contractor shall measure clinical outcomes, have these outcomes evaluated by clinical experts; identify quality management tools to be applied; and recommend changes in clinical practices intended to improve the quality of dental care to enrollees with developmental disabilities.

4.7.1.K. The contractor shall produce reports of all PCPs in its network (regardless of panel size), who are treating children under 21 years old, that provide information to the PCPs of underutilization or no utilization of their enrollee panel members as compared to EPSDT utilization requirements.

Exhibit 10.6.9

4.7.2 EVALUATION AND REPORTING — CONTRACTOR RESPONSIBILITIES

A. The contractor shall collect data and report tot eh State its findings on the following:

1. Encounter Data: the contractor shall prepare and submit encounter data to DMAHS in accordance with Article 3.9.Instructions and formats for this report are specified in Section B.3.3 of the Appendices of this contract.

2. Grievance Reports: the contractor shall provide to DMAHS quarterly reports of all grievances in accordance with Articles 5.15 and the contractor’s approved grievance process included in this contract. See Section A.7.5 of the Appendices (Table 3).

3. Appointment Availability Studies: The contractor shall conduct a review of appointment availability and submit a report to DMAHS annually. The report must list the average time that enrollees wait for appointments to be scheduled in each of the following categories: baseline physical, routine, specialty, and urgent care appointments. DMAHS must approve the methodology for this review in advance in writing. The contractor shall assess the impact of appointment waiting times on the health status of enrollees with special needs.

4. Twenty-four (24) Hour Access Report: the contractor shall submit to DMAHS an annual report describing its twenty-four (24) hour access procedures for enrollees. The report must include the names and addresses of any answering services that the contractor uses to provide twenty-four (24) hour access.

5. The contractor shall submit to DMAHS, on a quarterly basis, the number of early discharges that pertain to hospital stays for newborns and mothers.

6. The contractor shall monitor, evaluate and submit an annual report to DMAHS on the incidence of HIV/AIDS patients, the impact of the contractor’s program to promote HIV prevention (Article 4.5.7), counseling, treatment and quality of life outcomes, mortality rates.

7. Additional Reports: The contractor shall prepare and submit such other reports as DMAHS may request. Unless otherwise required by law or regulation, DMAHS shall determine the timeframe for submission based on the nature of the report and give the contractor the opportunity to discuss and comment on the proposed requirements before the contractor is required to submit such additional reports.

Exhibit 10.6.9

understanding that the contractor may permit a more liberal, direct specialty access (See section 4.5.2) to a specific specialist for the explicit purpose of meeting those specific specialty service needs. The PCP shall in this case retain all responsibility for provision of primary care services and for overall coordination of care, including specialty care.

5. If the enrollees’ existing PCP is a participating provider in the contractor’s network, and if the enrollee wishes to retain the PCP, contractor shall ensure that the PCP is assigned, even if the PCP’s panel is otherwise closed at the time of the enrollee’s enrollment.

C. In addition to offering, at a minimum, a choice of two or more primary care physicians, the contractor shall also offer an enrollee, or where applicable, and authorized person the option of choosing a certified nurse midwife, certified nurse practitioner or clinical nurse specialist whose services must be provided within the scope of his/her license. The contractor shall submit to DMAHS for review a detailed description of the CNP/CNS’s responsibilities and health care delivery system within the contractor’s plan.

4.8.3 PROVIDER NETWORKFILE REQUIREMENTS

The contractor shall provide a certified [See appendix A.4.4 for form] provider network file monthly, to be reported by hard copy and electronically in a format and software application system determined by DMAHS that will include the names and addresses of every provider in the contractor’s network. The file shall be submitted electronically by the close of business on the fourth Monday of every month. This includes all contracted providers and required established relationships. It excludes all non-participating providers. The format for computer diskette electronic submission is found in Section A.4.1 of the Appendices.

A. The contractor shall provide the DMAHS a full network, monthly, on computer diskette electronically in accordance with the specifications provided in Section A.4.1 of the Appendices. The contractor shall phase-in use of HIPAA Taxonomy Specialty Codes with full implementation by January 2007. The network file shall include an indicator for new additions and deletions and shall include:

     1. Any and all changes in participating primary care providers, including, for example, additions, deletions, or closed panels, must be reported monthly to DMAHS.

Exhibit 10.6.9

     2. Any and all changes in participating physician specialists, health care providers, CNPs/CNSs, ancillary providers, and other subcontractors must be reported to DMAHS on a monthly basis.

     3. The contractor shall not allow enrollment freezes for any provider unless the same limitations apply to all non-Medicaid/NJ FamilyCare members as well, or contract capacity limits have been reached.

Exhibit 10.6.9

B. DMAHS review of provider network deficiencies will be conducted on a quarterly basis or more frequently as may be required.

C. The contractor shall provide the HBC with a full network on a monthly basis in accordance with the specifications found in Section A.4.1 of the Appendices. The electronic files shall be sent to DMAHS, and a hard copy to the DMAHS’ designee for distribution.

1. The contractor will receive an electronic “HMO Provider Network Response” file from the State in response to the monthly provider network file submitted to the State by the contractor. The file will contain the pre-existing Medicaid ID or the assigned pseudo-Medicaid ID for each network provider. This response file will contain the same fields and records submitted to the State by the contractor and the State will value the Medicaid or pseudo-Medicaid Provider ID field for each record. The contractor shall use the Medicaid or pseudo-Medicaid Provider IDs as a secondary identifier on all encounter data submitted to the State.

4.8.4 PROVIDER DIRECTORY REQUIREMENTS

The contractor shall prepare a provider director which shall be presented in the following manner. Fifty (50) copies of the provider directory, and any updates, shall be provided to the HBC, and ten (10) copies shall be provided to DMAHS at least every six months or within 30 days of an update.

A. Primary care providers who will serve enrollees listed by

	•		County, by city by specialty
	•		Provider name and degree; specialty board eligibility/certification status; office address(es) (actual street address); telephone number; fax number if available; office hours at each location; indicate if a provider services enrollees with disabilities and how to receive additional information such as type of disability; hospital affiliations, transportation availability; special appointment instructions if any; languages spoken; disability access; and any other pertinent information that would assist the enrollee in choosing a PCP.

B. Contracted specialists and ancillary services providers who will service enrollees Listed by county, by city, by physician specialty, by non-physician specialty, and by adult specialist and by pediatric specialist for those specialties indicated in Section 4.8.8.C.

C. Subcontractors

Exhibit 10.6.9

Contracting, as a consultant, or on a referral basis. Payment mechanism and rates shall be negotiated directly with the center.

C. The contractor shall include primary care providers experienced in caring for enrollees with special needs (See A.4.1 provider network file).

4.8.7.D. The contractor shall include providers who have knowledge and experience in identifying child abuse and neglect and should include Child Abuse Regional Diagnostic Centers (Section B.4.16 of the Appendix) or their equivalent through either direct contracting, as a consultant or on a referral basis. A list of Child Abuse Regional Diagnostic Centers is in Section B.4.16 of the Appendices.

E. The contractor shall have a procedure by which an enrollee who needs ongoing care from a specialist may receive a standing referral to such specialist. If the contractor or the primary care provider in consultation with the contractor’s medical director and specialist, if any, determines that such a standing referral is appropriate, the organization shall make such a referral to a specialist. The contractor shall not be required to permit an enrollee to elect to have a non-participating specialist if a network provider of equivalent expertise is available. Such referral shall be pursuant to a treatment plan approved by the contractor in consultation with the primary care provider, the specialist, the care manager, and the enrollee, or , where applicable, authorized person. Such treatment plan may limit the number of visits or the period during which such visits are authorized and may require the specialist to provide the primary care provider with regular updates on the specialty care provided, as well as all necessary medical information.

F. The contractor shall have a procedure by which an enrollee as described in Articles 4.5.2.D may receive a referral to a specialist or specialty care center with expertise in treating such conditions in lieu of a traditional PCP.

G. If the contractor determines that it does not have a health care provider with appropriate training and experience in its panel or network to meet the particular health care needs of an enrollee, the contractor shall make a referral to an appropriate out-of-network provider, pursuant to a treatment plan approved by the contractor in consultation with the primary care provider, the non- contractor participating provider and the enrollee or where applicable, authorized person, at no additional cost

Exhibit 10.6.9

to the enrollee. The contractor shall provide for a review by a specialist of the same or similar specialty as the type of physician or provider to whom a referral is required before the contractor may deny a referral.

4.8.8 PROVIDER NETWORK REQUIREMENTS

Provider networks and all provider types within the network shall be reviewed on a county basis, i.e., must be located within the county except where indicated, (See also Section 4.8.8M.). The contractor shall monitor the capacity of each of its providers and decrease ratio limits as needed to maintain appointment availability standards.

Exhibit 10.6.9

F. The contractor shall also establish relationships with physician specialist and subspecialists [Non-Institutional file] through a contract, as a consultant, or on a referral basis for:

1. Dental Specialists — Required relationships for dental conditions that require specialists for

a. Prosthodontia

b. Endodontia

c. Periodontia

2. Pain Management

3. Medical Genetics

4. Developmental-Behavioral Pediatrics

G. Specialty Centers (Centers of excellence) shall be included in the network either through a contract, as a consultant, or on a referral basis [Institutional File].

1. Providers and health care facilities for the care and treatment of HIV/AID (list of for available centers, found in see section B.4.13 of the Appendices Appendix).

2. Special Child Health services Network Agencies for:

a. Pediatric Ambulatory Tertiary Centers

b. Regional Cleft Lip/Palate Centers

c. Pediatric HIV Treatment Centers

d. Comprehensive Regional Sickly Cell/Hemoglobinpathies Treatment Centers

e. PKU Treatment Centers

f. Other as designated from time to time by the Department of Health and Senior Services.

3. Other

a. Genetic Testing and Counseling Centers

b. Hemophilia Treatment Centers

H. Other Specialty Centers/Providers [Institutional File]

Contractor should establish relationships with the following providers/centers on a consultant or referral basis.

1. Spinal bifida Centers/providers

2. Adult Scoliosis

Exhibit 10.6.9

3. Autism and Attention Deficits

4. Spinal Cord Injury

5. Lead Poisoning Treatment Centers

6. Child Abuse Regional Diagnostic Centers

Exhibit 10.6.9

family planning services outside the contractor’s provider network are not covered services

N. A description of the process for referral to specialty and ancillary care providers and second opinions;

O. An explanation of the reasons for which an enrollee may request a change of PCP, the process of effectuating that change, and the circumstances under which such a request may be denied;

P. The reasons and process by which provider may request an enrollee to change to a different PCP.

Q. An explanation of an enrollee’s rights to disenroll or transfer at any time for cause; disenroll or transfer in the first 90 days after the latter of the date the individual enrolled or the date they receive notice of enrollment and at least every twelve (12) months thereafter without cause and that the lock-in period does not apply to ABD, DDD or DYFS individuals;

R. Complaints and Grievances/Appeals

1. Procedures for resolving complaints, as approved by the DMAHS;

2. A description of the grievance/appeal procedures to be used to resolve disputes between a contractor and an enrollee, including: the name, title, or department, address, and telephone number of the person(s) responsible for assisting enrollees in grievance/appeal resolutions; the time frames and circumstances for expedited and standard grievances; the right to appeal a grievance determination and the procedures for filing such an appeal; the time frames and circumstances for expedited and standard appeals; the right to designate a representative; a notice that all disputes involving clinical decisions will be made by a qualified clinical personnel; and that all notices of determination will include information about the basis of the decision and further appeal rights, if any;

3. The contractor shall notify all enrollees in their primary language of their rights to file grievances and appeal grievance decisions by the contractor;

5.8.2.S. An explanation that in addition to the HMO Appeal process, Medicaid/NY FamilyCare Plan A enrollees, and Plans D and H enrollees with a program status code of 380, have the right to a Medicaid Fair Hearing (which must be requested withink20 days of the date of the adverse action) with DMAHS and the appeal process through the DHSS for Medicaid and NJ FamilyCare enrollees, including instructions on the procedures involved in making such a request;

Exhibit 10.6.9

specialized medical care over a prolonged period of time may request a specialist or specialty care center responsible for providing or coordinating the enrollee’s medical care and the procedure for requesting and obtaining such a specialist or access to the center;

HH. A notice of all appropriate mailing addresses and telephone numbers to be utilized by enrollees seeking information or authorization;

II. A notice of pharmacy Lock-In program and procedure:

JJ. An explanation of the time delay of thirty (30) to forty-five (45) days between the date of initial application and the effective date of enrollment; however, during this interim period, prospective Medicaid enrollees will continue to receive health care benefits under the regular fee-for-service Medicaid program or the HMO with which the person is currently enrolled. Enrollment is subject to verification of the applicant’s eligibility for the Medicaid program and New Jersey Care 2000+ enrollment; and the time delay of thirty (30) to forty five (45 days between the date of request for disenrollment and the effective date of disenrollment.

KK. An explanation of the appropriate uses of the Medicaid/NJ FamilyCare identification card and the contractor identification card. ;

LL. A notification, whenever applicable, that some primary care physicians may employ other health care practitioners, such as nurse practitioners or physician assistants, who may participate in the patient’s care;

MM. The enrollee’s or, where applicable, an authorized person’s signed authorization on the enrollment application allows release of medical records.

5.8.2.NN. Notification that the enrollees’ health status survey information on the Plan Selection Form will be sent to the contractor by the enrollee Health Benefits Coordinator.

OO. A notice that enrollment and disenrollment is subject to verification and approval by DMAHS;

PP. An explanation of procedures to follow if enrollees receive bills from providers of services, in or out of network;

Exhibit 10.6.9

QQ. An explanation of the enrollee’s financial responsibility for payment when services are provided by a health care provider who is not part of the contractor’s organization or when a procedure , treatment or service is not a covered health care benefit by the contractor and/or by Medicaid;

Exhibit 10.6.9

Person of the enrollee’s disenrollment rights at least sixty (60) days prior to the end of his/her twelve (12) — month enrollment period. The contractor shall notify the enrollee of the effective disenrollment date.

D. Release of Medical Records. The contractor shall transfer or facilitate the transfer of the medical record (or copies of the medical record) upon the enrollee’s or, where applicable, and authorized person’s request, to either the enrollee, to the receiving provider, or, in the case of a child eligible through the Division of Youth and Family Services, to a representative of the Division of Youth and Famaly Services or to an adoptive parent receiving subsidy through DYFS, at no charge, in a timely fashion, i.e., no later than ten days prior to the effective date of transfer. The contractor shall release medical records of the enrollee, and/or facilitate the release of medical records in the possession of participating providers as may be directed by DMAHS authorized personnel and other appropriate agencies of the State of New Jersey, or the federal government. Release of medical records shall be consistent with the provision of confidentiality as expressed in Article 7.40 of this contract and the provisions of 42 C.F.R. 431.300. For individual being served through the Division of Youth and Family Services, release of medical records must be in accordance with the provisions under JNSA 9:6-8.10a and 9:6-8:40 and consistent with the need to protect the individual’s confidentiality.

E. in the event the contract, or any portion thereof, is terminated, or expires, the contractor shall assist DMAHS in the transition of enrollees to other contractors. Such assistance and coordination shall include, but not belimited to, the forwarding of medical and other records and the facilitation and scheduling of medically necessary appointments for care and services. The cost of reproducing and forwarding medical charts and other materials shall be borne by the contractor. Contractor shall be responsible for providing all reports set forth in this contract. The contractor shall make provision for continuing all management and administrative services until the transition of enrollees is completed and all other requirements of this contract are satisfied. The contractor shall be responsible for the following:

1. Identification and transition of chronically ill, high risk and hospitalized enrollees, and enrollees in their last four weeks of pregnancy.

2. Transfer of requested medical records.

Exhibit 10.6.9

5.10.2 DISENROLLMENT FROM THE CONTRACTOR’S PLAN AT THE ENROLLEE’S REQUEST

A. An individual enrolled in a contractor’s plan may be subject to the enrollment Lock-in period provided for in this Article. The enrollment Lock-In provision does not apply to SSI and New Jersey Care ABD individual, clients of DD or to individuals eligible to participate through the Division of Youth and Family Services.

1. An Medicaid and NJ FamilyCare Plan A enrollees are subject to the enrollment Lock In period and may initiate disenrollment or transfer for any reason during the first ninety days after the latter of the date the individual is enrolled or the date they receive notice of enrollment with a new contractor and at least every twelve (12) months thereafter without cause. NJ FamilyCare Plans B, C, D, and H enrollees will be subject to a twelve (12) month Lock In period.

a. The period during which an individual has the right to disenroll from the contractor’s plan without cause applies to an individual’s initial period of enrollment with the contractor. If that individual chooses to re-enroll with the contractor, his/her initial date of enrollment with the contractor will apply.

b. Upon automatic re-enrollment of an individual who is disenrolled solely because he or she loses Medicaid eligibility for a period of 2 months or less, if the temporary loss of Medicaid eligibility has caused the individual to miss the annual disenrollment opportunity.

2. An enrollee subject to the Lock in Period may initiate disenrollment for good cause at any time

a. Good cause reasons for disenrollment or transfer shall include unless otherwise defined by DMAHS:

i. Failure of the contractor to provide services including physical access to the enrollee in accordance with the terms of this contract;

ii. Enrollee has filed a grievance/appeal with the contractor pursuant to the applicable grievance/appeal procedure and has not received a response within the specified time period stated herein, or in a shorter time period required by federal law;

iii. Documented grievance/appeal by the enrollee against the contractor’s plan without satisfaction.

iv. Enrollee is subject to enrollment exemption as set forth in Article 5.3.2. If an exemption situation exists within the contractor’s plan but another contractor can accommodate the individual’s needs, a transfer may be granted.

Exhibit 10.6.9

6. Expected timeframes for disposition of grievances/appeals in accordance with NJAC8:38 et seq. and 42 CFR 438.408

7. Extensions of the grievance/appeal process if needed and time frames in accordance with 5.15.2.B.8 Fair hearing procedures including the Medicaid enrollee’s right to access the also file for a Medicaid Fair Hearing process at any time in addition to the HMO appeal to request resolution of a grievance/appeal

9. DHSS process for use of Independent Utilization Review Organization (IURO)

C. A description of the process under which an enrollee may file an appeal shall include at a minimum:

1. Title of person responsible for processing appeal

2. Title of person(s) responsible for resolution of appeal

3. Time deadlines for notifying enrollee of appeal resolution

4. The right to request a Medicaid Fair Hearing/DHSS IURO processes where applicable to specific enrollee eligibility categories

5.15.3 GRIEVANCE/APPEAL PROCEDURES

A. Availability. The contractor’s grievance/appeal procedure shall be available to all enrollees, or where applicable, an authorized person or permit a provider acting on behalf of an enrollee and with the enrollee’s consent. The procedure shall assure that grievance/appeals may be filed verbally directly wit the contractor.

B. The grievance/appeal procedure shall be in accordance with NJAC 8:38 et seq. and 42 CFR 438.438 subpart F.

C. DMAHS shall have the right to submit comments to the contractor regarding the merits or suggested resolution of any grievance/appeal.

By the fifteenth of every month the contractor shall submit electronically reports of all UM and non-UM enrollee grievance/appeal requests and dispositions directly to the DMAHS on the database format provided by DMAHS. The information submitted to DMAHS shall include information for the reporting month and all open cases to date and indicate the enrollee’s name, Medicaid/NJ FamilyCare number, date of birth, age, eligibility category, as well as the date of the grievance/appeal, resolution and the date of resolution.

Exhibit 10.6.9

D. Time limits to File. The contractor may provide reasonable time limits within which enrollees must file grievance/appeals, but such time period shall not e less than sixty (60) days and not to exceed 90 days from the date of the contractor’s notice of action. (Within that timeframe, the enrollee may file an appeal or request a State fair hearing). In the case of a Medicaid Fair Hearing, the enrollee must file a request within 20 days of the adverse action.

5.15.4 PROCESSING GRIEVANCES/APPEALS

A. Staffing. The contractor shall have an adequate number of staff to receive and assist with enrollee grievance/appeals by phone, in person and by mail. All staff involved in the receipt, investigation and resolution of complaints shall be trained on the contractor’s policies and procedures and shall treat all enrollees with dignity and respect.

B. grievance/appeal Forms. If the contractor uses a grievance/appeal form, the contractor must make available written grievance/appeal forms in the enrollee’s primary language in accordance with the multilingual definition. Such forms shall be readily available through the contractor upon request by telephone or in writing. The contractor shall mail the form within five (5) work days of receiving a telephone or written request. The contract shall permit grievance/appeals to be filed in writing, either on the contractor’s form ir in any other written format, by fax, or verbally. For appeals, an oral filing must be followed with a written, signed appeal except when the request is for expedited translation service to translate grievance/appeal forms in an enrollee’s primary language in order to meet the timeframes of this contract provision. A copy of the translated form shall be sent to DMAHS for post review.

C. Confidentiality. The contractor shall have written policies and procedures to assure enrollee confidentiality and reasonable privacy throughout the complaint and grievance/appeal process.

D. Non — Discrimination. The contractor shall have written policies to assure that the contractor or any provider or agent of the contractor shall not discriminate against an enrollee or attempt to disenrolll an enrollee for filing a complaint or grievance/appeal against the contractor.

E. Documentation. Upon receipt of a grievance/appeal, the contractor’s staff shall record the date of receipt, a written summary of the problem, the response given, the resolution effected, if any, and the department or staff personnel to whom the grievance/appeal has been routed. See article 5.15.5 for further information on records maintenance.

F. Tracking System. The contractor shall maintain a separate complaint log as well as a grievance/appeal tracking and resolution for Medicaid/NJ

Exhibit 10.6.9

Commission, percentage, brokerage or contingent fee, except bona fide employees or bona fide established commercial or selling agencies maintained by the contractor for the purpose of securing business. The penalty for breach or violation of this provision may result in termination of the contract without the State being liable for damages, cost and/or attorney fees or, in the Department’s discretion, a deduction from the contract price or consideration the full amount of such commission, percentage, brokerage or contingent fee.

▇. ▇▇▇▇▇▇▇▇ Principles. The contractor shall comply with the ▇▇▇▇▇▇▇▇ principles of nondiscrimination in employment and have no business operations in Northern Ireland as set forth in NJSA 52:34-12.1.

L. Ownership of Documents. All documents and records, regardless of form, prepared by the contractor in fulfillment of the contract shall be submitted to the State and shall become the property of the State

M. Publicity. Publicity and/or public announcements pertaining to the project shall be approved by the State prior to release. See Article 5.16 regarding Marketing

N. Taxes. Contractor shall maintain and produce to the Department upon request, proof that all appropriate federal and State taxes are paid.

7.3 STAFFING

In addition to complying with the specific administrative requirements specified in Articles Two through Six and Eight, the contractor shall adhere to the standards delineated below:

A. The contractor shall have in place the organization, management and administrative systems necessary to fulfill all contractual arrangements. The contractor shall demonstrate to DMAHS’ satisfaction that it has the necessary staffing, by function and qualifications, to fulfill its obligations under this contract which include at a minimum:

	•		A designated administrative liaison for the Medicaid/NJ FamilyCare contract who shall be the main point of contact responsible for coordinating all administrative activities for this contract (“contractor’s Representative”; See also Article 7.5 below)
	•		A medical director who shall be a New Jersey licensed physician (M.D. or D.O).
	•		A dental service coordinator
	•		Financial Officer(s) or accounting and budgeting officer

Exhibit 10.6.9

Liquidated Damages:

If the contractor does not provide or perform the requirement within fifteen (15) business days of the written notice, or longer if allowed by the Department, or through an approved corrective action plan, the Department may impose liquidated damages of $250 per requirement per day for each day the requirement continues not to be provided or performed. If after fifteen (15) additional days from the date the Department imposes liquidated damages, the requirement has still not been provided or performed, the Department, after written notice to the contractor, may increase the liquidated damages to $500 per requirement per day for each day the requirement continues to be unprovided or unperformed.

7.16.3 TIMELY REPORTING REQUIREMENTS

The contractor shall produce and deliver timely reports within the specified timeframes and descriptions in the contract including information required by the ERO. Reports shall be produced and delivered on both a scheduled and mutually agreed upon on-request basis according to the schedule established by DMAHS.

Liquidated Damages:

For each late report, the Department may impose liquidated damages of $250 per report per day until the report is provided. For any late report that is not delivered after thirty (30) days or such longer period as the Department shall allow, the Department, after written notice, shall have the right to increase the liquidated damages to $500 per day per report until the report is provided.

7.16.4 ACCURATE REPORTING REQUIREMENTS

Every report due the State shall contain sufficient and accurate information and in the approved media format to fulfill the State’s purpose for which the report was generated.

If the Department imposes liquidated damages, it shall give the contractor written notice of a report that is either insufficient or in accurate and that liquidated damages will be assessed accordingly. After such notice, the contractor shall have fifteen (15) business days, or such longer period as the Department may allow, to correct the report.

Encounter data shall be accurate and complete, i.e., have not missing encounters or required data elements, and shall have no more than 5% edit errors.

Exhibit 10.6.9

Liquidated Damages:

If the contractor fails to correct the report within the fifteen (15) business days, or such longer period as the Department may allow, the Department shall have the right to impose liquidated damages of $250 per day per report until the corrected report is delivered. If the report remains uncorrected for more than thirty (30) days from the date liquidated damages are imposed, the Department, after written notice, shall have the right to increase the liquidated damages assessment to $500 per day per report until the report is corrected.

The State will use encounter data completeness benchmarks to identify areas where encounter data appear to have been underreported. These benchmarks will be periodically revised to ensure that they are reasonable, and accurately reflect minimum reporting expectations. If the contractor falls outside of encounter data completeness benchmarks for any Managed Care Category of Service, the contractor will be notified that reporting deficiencies may have occurred for specified date ranges. In this event, the State may require documentation regarding the potential deficiency and/or a plan of corrective action from the contractor . If the contractor is unable to demonstrate that encounter data reports are complete, the State will conduct reviews of medical records, or utilize other means to determine reporting compliance. The State reserves the right to consider utilization rates reported via encounter data in the process of calculating capitation rates. Additionally the State reserves the right to reconsider the use of the benchmarks to measure reporting completeness.

In addition to conducting routine monitoring, the DMAHS will conduct, on a calendar year basis, annual reviews of encounter data to determine compliance performance. Encounter data will be reviewed for missing or omitted encounter data and for pending encounters or edit errors. An amount of $1 may be assessed for each missing or omitted encounter. Id addition, $1 per encounter or encounter data element may be assessed for any pending encounter or error that is not corrected and returned to DMAHS within thirty (30) days after notification by DMAHS that the data are incomplete or incorrect. The Department shall have the right to calculate the total number of missing or omitted encounters and encounter data by extrapolating from a sample of missing or omitted encounters and encounter data.

Exhibit 10.6.9

7.16.5 TIMELY PAYMENTS TO MEDICAL PROVIDERS

The contractor shall process claims in accordance with New Jersey laws and regulations and shall be subject to damages pursuant to such laws and regulations. In addition, pursuant to this contract the Department may assess liquidated damages if the contractor does not process (pay or deny) claims within the following timeframes: ninety (90) percent of all claims (the totality of claims received whether contested or uncontested) submitted manually by medical providers within thirty (30) days of receipt; ninety (90) percent of all claims filed electronically within forty (40) days of receipt; ninety-nine (99) percent of all claims , whether submitted electronically or manually, within sixty (60) days of receipt; and one hundred (100) percent of all claims within ninety (90) days of receipt. Claims processed for providers under investigation for fraud or abuse and claims suppressed pursuant to Article 8.9 (regarding PIPs) are not subject to these requirements.

The amount of time required to process a paid claim shall be computed in days by comparing the initial date of receipt with the check mailing date. The amount of time required to process a denied claim (whether all or part of the claim is denied) shall be computed in days by comparing the date of initial receipt with the denial notice mailing date. Claims processed during the quarter shall be reported in required categories through the Claims Lag report (see Section A.7.621 of the Appendices (Tables 4A and B)). Table 4A shall be used to report claims submitted manually and Table 4B shall be used to report claims submitted electronically.

Exhibit 10.6.9

Liquidated Damages

Liquidated damages may be assessed if the contractor does not meet the above requirements on a quarterly basis. Based on the contractor-reported information n the claims lag report, the Department shall determine for each time period (thirty (30)/forty (40), sixty (60), and ninety (90) days) the actual percentage of claims processed (electronic and manual claims shall be added together). This number shall be subtracted from the percentage of claims the contractor should have processed in the particular time period. The difference shall be expressed in points. For example, if the contractor only processed eighty-eight (88) percent of manual claims within forty days, it shall be considered to be two (20 pointes short for that time period. The points that the contractor is short for each of the three time periods shall be added together. This sum shall then be multiplied times .0004 times the compensation received by the contractor during the quarter at issue to arrive at the liquidation damages amount.

No offset shall be given if a criterion is exceeded. DMAHS reserves the right to audit and/or request detail and validation of reported information. DMAHS shall have the right to accept or reject the contractor report and may substitute reports created by DMAHS if contractor fails to submit reports or the contractor’s reports are found to be unacceptable.

7.16.6 CONDITIONS FOR TERMINATION OF LIQUIDATED DAMAGES

Except as waived by the Contracting Officer, no liquidated damages imposed on the contractor shall be terminated or suspended until the contractor issues a written notice of correction to the Contracting Officer certifying the correction of condition(s) for which liquidated damages were imposed and until all contractor corrections have been subjected to system testing or other verification at the discretion of the Contracting Officer. Liquidated damages shall cease on the day of the contractor’s certification only if subsequent testing of the correction establishes that, indeed, the correction has been made in the manner and at the time certified to by the contractor.

A. the contractor shall provide the necessary system time to system test any correction the Contracting Officer deems necessary.

Exhibit 10.6.9

Iv Achievement of less than 30 percent lead screening rate: refund of $5 per enrollee for all enrollees under age 3 not screened.

b. Discretionary sanction. The DMAHS shall have the right to impose a financial or administrative sanction if the contractor’s performance screening rate is between sixty (60) and seventy (70) percent. The DMAHS, in its sole discretion, may impose a sanction after review of the contractor’s corrective action plan and ability to demonstrate good faith efforts to improve compliance.

7.16.7.B.2. Failure to achieve and maintain the required screening rate shall result in the Local Health Departments being permitted to screen the contractor’s pediatric members. The cost of these screening shall be paid by the DMAHS to the LHD, and the screening cost shall be deducted from the contractor’s capitation rate in addition to the damages imposed as a result of failure to achieve lead screening performance standards.

3. Mandatory sanctions may be offset when the contractor demonstrates improved compliance. The division, in is sole discretion, may reduce the sanction amount by $1 for each twelve (12) point improvement over prior reporting period performance rate. Offsets shall not reduce the financial sanction amount to below $1 per enrollee not screened.

C. The contractor must deomonstrate continuous quality improvement in achieving the performance standard for EPSDT and elad screenings as stated in Article 4. The Division shall, in its sole discretion, determine the appropriateness of v imposed corrective action and the imposition of any other financial or administrative sanction in addition to those set out above.

7.16.8 DEPARTMENT OF HEALTH AND HUMAN SERVICES CIVIL MONEY PENALITIES

7.16.8.1 FEDERAL STATUTES

Pursuant to 42 U.S.C§ 1396B(m)(5)(A), the Secretary of the Department of Health and Human Services may impose substantial monetary and/or criminal penalties on the contractor when the contractor:

A. fails to substantially provide an enrollee with required medically necessary items and services, required under law or under contract to be provided to an enrolled beneficiary, and the failure has adversely affected the enrollee or has substantial likelihood of adversely affecting the enrollees.

Exhibit 10.6.9

B. Imposes premiums or charges on enrollees in violation of this contract, which provides that no premiums, deductibles, co-payments or fees of any kind may be charged to Medicaid enrollees.

Exhibit 10.6.9

Quality assurance studies or projects; prospective, concurrent, and retrospective utilization reviews of inpatient hospital stays and denials of off-formulary drug requests.

7.26.F. the contractor shall prepare and submit to DMAHS quarterly reports to be submitted reported electronically (e.g., email) in report-ready form by hard copy and diskette in a format and software application system determined by DMAHS, containing summary information on the contractor’s operations for each quarter of the program. (See Section A.7 of the Appendices, Tables 1 though 2122. Exceptions — Tables 3A and 3B shall be submitted monthly by the fifteenth (15^th ) of every month; Tables 5 and 7 shall be submitted annually). These reports shall be receive by DMAHS no later than forty-five (45 ) calendar days after the end of the quarter. After a grace period of five (5) days, for each calendar day after a due date the DMAHS has not yet received at a prescribed location a report that fulfills the requirements of any one item, assessment for damages equal to one half month’s negotiated blended capitation rate that would normally be owed by the DMAHS to the contractor for one recipient shall be applied. The damages shall be applied as an offset to the subsequent payments to the contractor.

The contractor shall be responsible for continued reporting beyond the term of the contract because of lag time in submitting source documents by providers.

g. The contractor may submit encounter reports daily but must submit encounter reports at least quarterly . However, encounter reports will be processed by DMAHS’ fiscal agent no more frequently than monthly. All encounters shall be reported to DMAHS within seventy-five (75) days of the end of the quarter in which they are received by the contractor and within one year plus seventy-five days from the date of service.

H. The contractor shall annually and at the time changes are made report its staffing position including the names of supervisory personnel (Director level and above and the QM/UR personnel), organizational chart, and any position vacancies in tehse major areas.

I. DMAHS shall have the right to create additional reporting requirements at any time as they are required by applicable federal or State laws and regulations, as they exist or may hereafter be amended and incorporated into this contract.

Exhibit 10.6.9

J. Reports that shall be submitted on an annual or semi-annual basis, as specified in this contract, shall be due within sixty (60) days of the close of the reporting period, unless specified otherwise.

K. MCSA Paid Claims Reconciliation. On a quarterly basis, the contractor shall provide paid claims data, via an encounter data file or separate paid claims file, that meet the HIPAA format requirements for audit and reconciliation purposes.

Exhibit 10.6.9

The contractor shall provide documentation that demonstrates a 100% reconciliation of the amounts paid to the amounts billed to the DMAHS. The paid claims data shall include at a minimum, claim type, provider type, category of service, diagnosis code (5 digits), procedure/revenue code, Internal Control Number or Patient Account Number under HIPAA, provider ID, dates of services, that will allow the DMAHS to price claims in comparison to Medicaid fee schedules for evaluation purposes.

L. Encounter Data Submissions. The contractor shall cooperate with the DMAHS in its review of the status of encounter data submissions to determine needed improvements for accuracy and completeness of encounter data submissions. With the contract period beginning July 2005, the contractor will be subject to additional sanction if not in full compliance with encounter data submission standards.

7.27. FINANCIAL STATEMENTS

7.27.1 AUDITED FINANCIAL STATEMENTS (SAP BASIS)

A. Annual Audit. The contractor shall submit its audited annual financial statements prepared in accordance with Statutory Accounting Principles (SAP) certified by an independent public accountant no later than June 1 of each year, for the immediately preceding calendar year as well as for any company that is a financial guarantor for the contractor in accordance with NJSA 8:38-11.6.

B. Audit of Income Statements by Rate Cell Grouping Costs

The contractor shall submit quarterly, reports found in Appendix, Section A in accordance with the “HMO Financial Guide for Reporting Manual for Medicaid/NJ FamilyCare Rate Cell Grouping Costs” (appendix, Section B7.3A7.21). these reports shall be reviewed by an independent public accountant in accordance with the standard “Agreed Upon Procedures” procedures and for the cost categories that will be detailed by DMAHS on or before December 31 each year, to be effective the following July. (Appendix, Section BA).

The contractor shall require its independent public accountant to prepare a letter and report of finding which shall be submitted to DMAHS by June 1 of each year. Only the fourth quarter report (period October through December 31) of each calendar year will be subject to this agreed upon procedures a Audit of Income Statements by Rate Cell Grouping.

Exhibit 10.6.9

The contractor shall require its independent public accountant to explain any differences between the Statewide Income Statement by Rate Cell Grouping Cost Reports (Report 2 – Parts S1 through S3) and the annual audit statements in the letter.

Exhibit 10.6.9

4. Has been convicted for an offense that occurred after the date of the enactment of the Health Insurance Portability and Accountability Act of 1996 of a criminal offense consisting of a felony relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.

7.38 FRAUD AND ABUSE

The contractor shall have arrangements and procedures that comply with all state and federal statutes and regulations, including 42 CFR 438.608 governing fraud and abuse requirements.

7.38.1 ENROLLEES

A. Policies and procedures. The contractor shall establish written policies and procedures for identifying potential enrollee fraud and abuse. Proven cases are to be referred to the Department for screening for advice and/or assistance on follow-up actions to be taken. Referrals are to be accompanied by all supporting case documentation.

B. Typical Cases. The most typical cases of fraud or abuse include but are not limited to: the alteration of an identification card for possible expansion of benefits, the loaning of an identification card to others; use of forged or altered prescriptions; and mis-utilization of services.

7.38.3 PROVIDERS

A. Policies and Procedures. The contractor shall establish written policies and procedures for identifying, investigating, and taking appropriate corrective action against fraud and abuse (as defined in 42 CFR§ 455.2) in the provision of health care services. The policies and procedures will include, at a minimum:

1. Written notification must be sent by the contractor to DMAHS within 5 business days of the contractor’s intent to conduct an investigation or to recover funds and approval must e obtained by the contractor from DMAHS prior to conducting the investigation or attempting to recover funds. Details of potential investigations shall be provided to DMAHS and include the data elements in Section A72B of the Appendices. Representatives of the contractor may be required to present the case to DMAHS. DMAHS in consultation with the contractor will then determine the appropriate course of action to be taken.

Exhibit 10.6.9

Written notification must be sent by the contractor to DMAHS within five (50 business days of the contractor’s intent to recover fund, and approval must be obtained by the contractor from DMAHS prior to collection of those funds.

2. Incorporation of the use of claims and encounter data for detecting potential fraud and abuse of services.

3. A means to verify services were actually provided.

4. Reporting investigation results within twenty (20) business days to DMAHS.

5. Specifications of, and reports generated by, the contractor’s prepayment and postpayment surveillance and utilization review systems, including prepayment and postpayment edits.

B. Distinct Unit. The contractor shall establish a distinct fraud and abuse unit, solely dedicated to the detection and investigation of fraud and abuse by its New Jersey Medicaid/NJ FamilyCare beneficiaries and providers It shall be separate from the contractor’s utilization review and quality of care functions. The unit can either be part of the contractor’s corporate structure, or operate under contract with the contractor.

1. The unit shall be staffed with investigators who shall have at least one of the following: (1) a Bachelor’s degree; (2) an Associate’s degree plus a minimum of two years experience with health care related employment; (3) a minimum of four years experience with health care related employment; or (4) a minimum of five years of law enforcement experience. When approved by DMASH, the contractor shall be permitted to employ a limited number of specialist who shall possess unique qualifications by way of training, technical skill and/or experience to investigate and identify cases of fraud, but who lack the specific educational requirements set forth above to be investigators. The unit shall have an investigator to beneficiary ratio for the New Jersey Medicaid/NJ FamilyCare enrollment of at least one investigator per 60,000 or fewer New Jersey enrollees or a greater ratio as needed to meet the investigative demands. The requirement of at least on investigator per 60,000 or fewer New Jersey enrollees can be satisfied by the use of full-

Exhibit 10.6.9

time equivalents rather than dedicated investigators, but only if the contractor submits to DMAHS on a quarterly basis the statistics ask for in Section A.7.2 of the Appendix documenting that at least one full-time equivalent investigator per 60,000 or fewer enrollees is being devoted to DMAHS-related fraud and abuse cases.

2. Claims analysts who are reviewing claims specifically for trends of fraud and/or abuse can be counted toward the FTEs. However, reviewing claims primarily for quality of care may not be counted. Exclusive use of

Exhibit 10.6.9

8.4 MEDICAL COST RATIO

8.4.1 MEDICAL COST RATIO STANDARD

The contractor shall maintain direct medical expenditures for enrollees equal to or greater than eighty (80) percent of premiums paid in all forms from the State. This medical cost ratio (MCR) shall apply to annual periods from the contractor effective date (if the contract ends before the completion of an annual period, the MCR shall apply to that shorter period). The MCR shall be based on reports completed by the contractor and acceptable to the Department.

A. Direct Medical Expenditures. Direct medical expenditures are the incurred cots of providing direct care to enrollees for covered health care services as stated in Article 4.1 (Report on Table 19s 6a and 6b6). Costs related to information and materials for general education and outreach and/or administration are not considered direct medical expenditures.

Personnel costs are generally considered to be administrative in nature and must be reported as an administrative expense to Table 19s 6a and 6b6 (Income statement by Rate Cell Grouping of Revenues and Expenses) on line 3029 for (compensation). However, a portion of these costs may qualify as direct medical expenditures, subject to prior review and approval by the State. Those activities that the contractor expects to generate these costs must be specified and detailed in a Medical Cost Ratio-Direct Medical Expenditures Plan which must be reviewed and approved by the State. At the end of the reporting period, the contractor’s reporting shall be based only on the approved Medical Cost Ratio- Direct Medical Expenditures Plan. In order to consider these costs as Direct Medical Expenditures, the contractor must complete Table 6e, entitled “Allowable Direct Medical Expenditures,” which will be used by the State to determine the allowable portion of the costs. The allowable components of these personnel costs include the following activities:

1. Care Management. Allowable direct medical expenditures for care management include: 1) assessment(s) of an enrollee’s risk factors; and 2)development of Individual Health Care Plans. The costs of performing these two allowable components may be considered a direct medical expenditure for purposes of calculating MCR and must be reported on Table 6c.

2. The cost associated with the provision of a face-to-face home visit by the contractor’s clinical personnel for the purpose of medical education or anticipatory guidance can be considered a direct medical expenditure (Report on Table 6c.

Exhibit 10.6.9

3. Costs for activities required to achieve compliance standards for EPSDT participation, lead screening, and prenatal care as specified in Article IV may be considered direct medical expenditures. The contractor’s reporting shall be based only on the approved Medical Cost Ratio- Direct Medical Expenditures Plan (report on Table 6c).

Calculation of MCR. The calculation of MCR will be made using information submitted by each contractor on the quarterly reports — Income Statement by Rate Cell Grouping of Revenues and Expenses (Section A.7.8 21 of the Appendices, (Tables 6a, 6b and 6c 19)). The costs related to 8.4.1.A 1 -3 are to be reported on Table 6c and the allowable amount will be added to the calculation of Medical and Hospital Expenses (lines 28) less Coordination of Benefits (COB) (line 6) and less reinsurance recoveries (line 7) will be divided by the sum of all applicable quarter of Medicaid/NJ FamilyCare premiums (line 4) to arrive at the ratio.

8.4.2 RESERVED

8.4.3 DAMAGES

The Department shall have the right to impose damages on a contractor that has failed to maintain an appropriate MCR. The damages shall be assessed when MCR is below 80% and an underexpenditure occurs. The formula for imposing damages follows:

ACTUAL MCR		1st OFFENSE		2ND OFFENSE
80% or above		NONE		NONE
78.00% — 79.99%		.15 times underexpenditure		.15 times underexpenditure
75.00 — 77.99%		.50 times underexpenditure		.50 times underexpenditure
74.99 or below		.90 times underexpenditure		.90 times underexpenditure

If the contractor fails to meet the MCR requirement and a penalty is applied, a plan of corrective action shall be required.

Exhibit 10.6.9

8.5 REGIONS, PREMIUM GROUPS, AND SPECIAL PAYMENT PROVISIONS

8.5.1 REGIONS

Capitation rates for DYFS NJ FamilyCare Plans B, C, and D and the non risk-adjusted rates for AIDS and clients of DD are statewide. Rates for all other premium groups are regional in each of the following regions:

	•		Region 1: Bergen, Hudson, Hunterdon, ▇▇▇▇▇▇, Passaic, Somerset, Sussex, and ▇▇▇▇▇▇ counties
	•		Region 2: Essex, Union, Middlesex, and ▇▇▇▇▇▇ counties
	•		Region 3: Altantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Monmouth, Ocean, and Salem Counties

Contractors may contract for one or more regions but, except as provided in Article 2, may not contract for part of a region.

8.5.2 MAJOR PREMIUM GROUPS

The following is a list of the major premium groups. The individual rate groups (e.g. children under 2 years, etc.) with their respective rates are presented in the rates tables in the appendix.

8.5.2.1 AFDC/TANF, NJJC PREGNANT WOMEN, AND NJ FAMILYCARE PLAN A CHILDREN

This grouping includes capitation rates for Aid to Families with Dependent Children (AFDC)/Temporary Assistance for Needy Families (TANF), New Jersey Care Pregnant Woman and Children, and NJ FamilyCare Plan A children (includes individual under 21 in PSC 380), but excludes individual who have AIDS or are clients of DDD, as well as AFCD/TANF restricted alien individual over the age of 20.99 years old.

8.5.2.2 NJ FAMILYCARE PLANS B &C

This grouping includes capitation rates for NJ FamilyCare Plans B and C enrollees, excluding individuals with AIDS and/or DDD Clients.

8.5.2.3 NJ FamilyCare PLAN D CHILDREN

This grouping includes capitation rates for NJ FamilyCare Plan D children excluding individuals with AIDS.

Exhibit 10.6.9

8.5.2.4 NJ FamilyCare PLAN D PARENTS/CARETAKERS

This grouping includes capitation rates for NJ FamilyCare Plan D parents/caretakers, excluding individuals with AIDS, and restricted alien individuals, and include only enrollees 19 years of age or older.

Exhibit 10.6.9

8.5.4 SUPPLEMENTAL PAYMENT PER PREGNANCY OUTCOME (Not applicable to Plan H).

Because cost for pregnancy outcomes were not included in the capitation rates, the contractor shall be paid supplemental payments for pregnancy outcomes for all eligibility categories.

Payment for pregnancy outcome shall be a single, predetermined lump sum payment. This amount shall supplement the existing capitation rate paid. The Department will make a supplemental payment to contractors following pregnancy outcome. For purposes of this Article, pregnancy outcome shall mean each live birth, still birth or miscarriage occurring at the thirteenth (13^th) or greater week of gestation. This supplemental payment shall reimburse the contractor for its inpatient hospital, antepartum, and postpartum costs incurred in connection with delivery. Costs for care of the baby for the first 60 days after the birth plus through the end of the month in which the 60^th day falls are included (see Section 8.5.3). Regional payment shall be made by the State to the contractor based on submission of a financial summary report of hospital and/or birthing center claims paid for final pregnancy outcomes. No other services, in patient hospital or otherwise, rendered prior to final pregnancy outcome shall qualify or be payable for a maternity supplement.

The report shall be accompanied by a signed certification form and an electronic file to include:

1. Paid inpatient hospital/birthing center claims;

2. Name of mother;

3 Mothers Medicaid identification number;

4. Newborn’s name, if known;

5. Diagnosis and five-digit ICD-9 codes, including V-codes, specified by DMAHS, and

6. Place of service.

The contractor shall continue to submit encounter data that will document each paid claim reported on the financial summary report. The DMAHS will conduct a reconciliation of these paid claims utilizing encounter data.

8.5.5 PAYMENT FOR CERTAIN BLOOD CLOTTING FACTORS

The contractor shall be paid separately for factor VIII and IX blood clotting factors. Payment will be made by DMAHS to the contractor based on; 1) submission of appropriate encounter data; and 2) notification from the contractor to DMAHS within 12 months of the date of service of

Exhibit 10.6.9

identification of individual with factor VIII or IX hemophilia. Payment for these products will be lesser of 1)Average Wholesale Price (AWP) minus 12.5% and 2)rates paid by the contractor.

8.5.6 PAYMENT FOR HIV/AIDS DRUGS

The contractor shall be paid separately for protease inhibitors and other anti-retroviral agents (First Data Bank Specific Therapeutic Class Codes W5C, W5B, W5I, W5J, W5K, ▇▇▇, ▇▇▇, ▇▇▇). Payment for protease inhibitors shall be made by DMAHS to the contractor based on 1)submission of appropriate encounter data; and 2) notification from the contractor to DMAHS within 12 months of the date of service of identification of individuals with HIV/AIDS. Payment for these products will be the lesser of 1)Average Wholesale Price (AWP) minus 12.5% and 2) rates paid by the contractor.

Individuals eligible through NJ FamilyCare Plans A, B, C and only those Plan D enrollees with a program status code of 380 and all children groups shall receive protease inhibitors and other anti-retroviral agents under the contractor’s plan. All other individual eligible through NJ FamilyCare P with program status codes of 497-498, 300-301, 700-701, and 763, and all Plan H individuals shall receive protease inhibitors and other anti-retrovirals (First Date Bank Specific Therapeutic Class Codes W5C, W5B, W5I, W5J, W5K, W5L, W5M, and W5N) through Medicaid fee for service and/or the AIDS Drug Distribution Program (ADDP).

8.5.7 EPSDT INCENTIVE PAYMENT

     the contractor shall be paid separately, $10 for every documented encounter record for a contractor-approved EPSDT screening examination. The contractor shall be required to pass the $10 amount directly to screening provider.

The incentive payment shall be reimbursed for EPSDT encounter records submitted in accordance with 1) procedure codes specified by DMAHS, and 2) EPSDT periodicity schedule.

8.5.8 ADMINISTRATIVE COSTS RESERVED

The capitation rates, effective July 1, 2003 recognize costs for anticipated contractor administrative expenditures due to Balanced Budge Act regulations.

8.5.9 NJ FAMILYCARE PLAN H ADULTS

Exhibit 10.6.9

The contractor shall be paid an administrative fee for NJ FamilyCare Plan H adults without dependent children, and restricted alien parents excluding pregnant women as defined in Article One.

8.6 HEALTH BASED PAYMENT SYSTEM (HBPS) FOR THE ABD POPULATION WITHOUT MEDICARE

The DMAHS shall utilize a Health-Based Payment System (HBPS) for reimbursements for the ABD population without Medicare to recognize larger average health care costs and the greater dispersion around the average than other DMAHS populations. The contractor shall be reimbursed not only on the basis of the demographic cells into which individuals fall, but also on the basis of individual health status.

Exhibit 10.6.9

Number, date of accident/incident, nature of injury, name and address of enrollee’s legal representative, copies of pleadings, and nay other documents related to the action in the contractor’s possession or control. This shall include, but not limited to (for each service date on or subsequent to the date of the accident/incident), the name of the provider, practitioner or subcontractor, the enrollee’s diagnosis, the nature of the service provided to the enrollee, and the amount paid to the provider (or to a provider’s authorized subcontractor) by the contractor for each service. A form is available for this purpose and is included in Section A.8.2 of the Appendices.

8.7.H.3. The contractor shall notify the State within thirty (30) days of the date it becomes aware of the death of one of its Medicaid enrollees age fifty-five (55) or older, giving the enrollees full name, Social Security Number, Medicaid identification number, and the date of death. The State will then determine whether it can recover correctly paid Medicaid benefits from the enrollee’s estate. (See ▇▇▇▇▇▇▇▇ ▇.▇.▇, ▇▇▇▇▇▇ Referral Form)

4. The contractor agrees to cooperate with the State’s efforts to maximize the collection of third party payments by providing to the State updates to the information required by this Article.

I. Enrollment Exclusions and Contractor Liability for the Costs of Care.

1. Any Medicaid beneficiary enrolled in or covered by either a Medicare or commercial HMO will not re enrolled by the contractor. The only exception to this exclusion from enrollment is when the contractor and the beneficiary’s Medicare/commercial HMO are the same. When beneficiaries are enrolled under this exception, appropriate reductions will be made in the State’s capitation payments to the contractor.

2. If the contractor and the Medicaid beneficiary’s Medicare or commercial HMO are the same, the contractor will be responsible for either:

a. Paying all cost-sharing expenses of the Medicaid beneficiary; or

b. Addressing cost sharing in the contracts with its providers in such a way that the Medicaid beneficiary is not liable for any cost sharing expenses, subject to the subarticle 3 below.

Exhibit 10.6.9

3. If a Medicaid beneficiary otherwise covered by the provisions of subarticle 2 above wishes to utilize a provider outside of the Medicare or commercial HMO’s network, the HMO’s rules apply. Failure to follow the HMO’s rules relieves both the contractor and the State of any liability for

Exhibit 10.6.9

A.3.1 Monthly HMO Reconciliation Rile Reserved

The following is submitted by the contractor to DMAHS fiscal agent.

Exhibit 10.6.9

4.

State of New Jersey

HMO Reconciliation File		Effective Date
File Name

Data Set Name		Record Size – Bytes	Block Size

Element		Field Name		Chars				Bytes				Bytes # rel to 1		Format		Cobol Picture				Description and/or Remarks
1		Medicaid Number		12				12				1-12		Num		9(12)				Enrollee’s Medicaid Number
2		Last Name		▇▇				▇▇				▇▇-▇▇		AN		X(12)				Enrollee’s Last Name
3		First Name		7				7				25-31		AN		X(7)				Enrollee’s First Name
4		DOB		8				8				32-39		Num		9(8)				Enrollee’s Date of Birth
5		SSN		9				9				40-48		An		X(9)				Enrollee’s Social Security No.
6		Effect Enrollee		8				8				49-56		Num		9(8)				Effective date of enrollment mmddyyyy format
7		Disenroll Date		8				8				57-64		Num		9(8)				Disenrollment Date mmddyyyy format
8		Filler		▇▇				▇▇				▇▇-▇▇		An		X(33)				As Needed/If Needed
9		Plan Code		3				3				98-100		An		X(3)				###(078-098)

Exhibit 10.6.9

Exhibit 10.6.9

ATTACHMENT A

New Jersey Department of Human Services, Division of Medical Assistance and Health Services, Office of Managed
Health Care
HMO Non-Institutional Provider Network File Specifications

When

Field

Field Name

Size

Required

Definition

Example

1

Last Name

22

A

Individual Provider’s Surname; may include R. or III. Name of group or medical school is unacceptable

▇▇▇▇▇, ▇▇.

2

First Name

15

A

Providers First Name. should include middle initial. Name of group or medical schools is unacceptable

▇▇▇ ▇.

3

SSN

9

A

Provider’s Social Security Number. Do not use hyphens or spaces

150999999

4

Tax ID

9

B

Provider’s Tax ID Number. Do not use hyphens or spaces

229999999

5

Degree

5

A

MD, DO, etc. Do not use periods

DO

6

Primary

1

A

Is this a primary care provider? (y Or N) Do not indicate Y for dental providers

Y

7

Practice Name

45

B

Name of Practice if different than provider’s last name

▇▇▇▇▇ Family Practice

8

Address 1

60

A

Place where services are rendered. Always start with street number if one is contained in the actual address of the practice. “Serving This Area” is not acceptable.

▇▇▇ ▇▇▇▇ ▇▇

9

Address 2

30

B

Building Name, ▇▇ ▇▇▇ ▇▇▇.

▇▇▇▇▇ ▇

▇▇

▇▇▇▇

▇▇

A

Proper Name for Municipality in which practice office is located. No abbreviations

South Orange

11

State

2

A

Two Character State Abbreviation, NJ or other with rare exceptions

NJ

12

Zip

5

A

5 digit zip code

08888

13

Phone

15

A

For service address, include Area Code, prefix, and Number No spaces or dashes.

6095882705

14

County

2

A

Two digit code for county in which office is actually located

07

15

Office Hours

60

A

List days and hours when patients can be seen at this site.

▇▇-▇, ▇▇-▇, Th1-7

16

Specialty Code

3

A

See List. List only one per record

213

17

Age Restrictions

4

B

Speciality code in string field 16, 1st 2 = min age, 2nd 2 = max age, 0000 if none for a specialty. Omit if no specialty is limited

1234

18

Hosp Affl1

355

B

Code for Hhospital where provider has admitting privileges. *required for physicians, podiatrists &Oral Surgeons.

Newark-▇▇▇▇ Israel A1234

19

Hosp Affl2

355

B

If more than One

A1234

20

Hosp Affl3

355

B

If more than Two

A1234

21

Hosp Affl4

355

B

If more than Three

A1234

Exhibit 10.6.9

When

Field

Field Name

Size

Required

Definition

Example

22

Hosp Affl5

355

B

If more than Four

A1234

23

Languages

10

A

Must be at least one, even if English; See code list. No spaces/commas/Slashes/Hyphens, etc

EFG9

24

Plan Code

3

1

Three digit plan code

099

25

Panel Status

1

A

O = Open, F = Frozen (no new patients)

O

26

Specialty Name

30

A

Show one narrative specialty name per record

Family Practice

27

Panel Capacity

4

B

Potential Number of Members: PCPs & General Dentists, should not exceed 1500 unless authorized by DMAHS

1500

28

Members Assigned

4

B

Actual number of Members Assigned; PCPs & Dentists

900

29

Record Type

3

B

a = addition of record to file (excludes d) d = deletion of record from file (excludes a & c) s = multiple listing of provider, unique specialty l = multiple listing of provider, unique location Use all that apply. No commas. Spaces allowed.

s a

30

Date

10

A

Fill with date Network Update File or Application Network File was submitted to DMAHS mm/dd/yyyy

06/01/2000

31

Servicing County

4

B

If other than actual county; include a record for each county served. Out-of-county physicians may not be considered in applications except where specified in the contract

32

Total Hours

2

A

Total number of hours for record. Round down

20

33

Medicaid ID

7

A

Provider’s Medicaid assigned ID

1234567

34

Special Needs Indicator

5

A

Indicates provider has expertise serving specific populations. Use all OMHS special needs codes that apply to provider.

35

Handicapped Accessible

1

C

Use Y if facility is Handicapped Accessible

36

Taxonomy ▇▇▇

10

B

Health Care Provider Taxonomy Code

Alpha-Numeric according to instructions.

Exhibit 10.6.9

ATTACHMENT B

NEW JERSEY DEPARTMENT of Human Services, Division of Medical Assistance and Health
Services,
Office of Managed Health Care
HMO Institutional Provider Network File Specifications

When

Field

Field Name

Size

Required

Definition

Example

1

Provider Name

45

A

Doc’s Drugs

2

Provider Type

30

A

Pharmacy

3

Provider Tax ID

9

A

Provider’s Tax ID Number

22999999

4

Address 1

60

A

Always start with street number if one is contained in the actual address of the practice. “Serving This Area” is not acceptable.

▇▇ ▇▇▇▇ ▇▇.

5

Address 2

30

B

Building Name, ▇▇ ▇▇▇, ▇▇▇

▇▇▇▇▇ ▇

▇

▇▇▇▇

▇▇

A

Proper Name for Municipality in which practice office is located. No abbreviations

South Orange

7

State

2

A

Two Character State Abbreviation, NJ or other with rare exceptions

NJ

8

Zip

5

A

5 digit zip code

08888

9

Phone

15

A

For service address, include Area Code, prefix, and Number No spaces or dashes.

6095882705

10

County

2

A

Two digit code for county in which office is actually located

07

11

Plan Code

3

A

Three Digit Plan Code

099

12

Specialty Code

3

A

See Code List. Use one.

500

13

Servicing County

4

B

If other than actual county; Include a record for each county served. Out-of-county institutions may not be considered in application except where specified in the contract.

14

Date

10

A

Fill with date Network Update File or Application Network File was submitted to DMAHS mm/dd/yyyy

06/01/2000

15

Record Type

1

B

A = addition of record to file (excludes d) D = Deletion of record from file (excludes a)

a

16

Medicaid Id

7

B

Provider’s Medicaid assigned Id

1234567

17

Hospital Code

5

B

Unique Hospital Code

99999

18

Taxonomy code

10

B

Health care Provider Taxonomy Code

Alpha Numeric according to specifications.

Exhibit 10.6.9

ATTACHMENT E

Hospital Code List

Hospital Name		County Location		Codes
Ancora Psychiatric Hospital		Atlantic		P0101
Atlantic City Medical Center — City Division		Atlantic		H0102
Atlantic City Medical Center — Mainland Division		Atlantic		H0103
Bacharach Institute for Rehabilitation		Atlantic		▇▇▇▇▇
▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇ Memorial Hospital		Atlantic		R0106
Bergen Regional Medical Center		Bergen		H0201
Christian Health Care Center		Bergen		P0202
Englewood Hospital and Medical Center		Bergen		H0203
Hackensack University Medical Center		Bergen		H0204
Holy Name Hospital		Bergen		H0205
▇▇▇▇▇▇▇ Institution for Rehabilitation — ▇▇▇▇▇▇▇ North		Bergen		▇▇▇▇▇
▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
The Valley Hospital		Bergen		▇▇▇▇▇
▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ Heart and Lung Center		Burlington		S0302
Hampton Behavioral Health Center		Burlington		P0303
Marlton Rehabilitation Hospital		Burlington		R0304
Virtua Memorial Hospital ▇▇▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇-▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ Children’s Rehabilitation Hospital		Burlington		R0307
The ▇▇▇▇▇▇ Health System		Camden		H0401
▇▇▇▇▇▇▇ Memorial Hospital — ▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ Memorial Hospital — ▇▇▇ ▇▇▇▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
Our Lady of ▇▇▇▇▇▇▇ Medical Center		Camden		H0404
Virtua West Jersey Hospital — Berlin		Camden		▇▇▇▇▇
▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇ Hospital — Voorhees		Camden		H0406
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Memorial Hospital		Cape May		H0501

Exhibit 10.6.9

Hospital Name		County Location		Codes
Rehabilitation Hospital of South Jersey		Cumberland		▇▇▇▇▇
▇▇▇▇▇ ▇▇▇▇▇▇ Healthcare — ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
Columbus Hospital		Essex		▇▇▇▇▇
▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ Institution for Rehabilitation — ▇▇▇▇▇▇▇ East		Essex		R0705
▇▇▇▇▇▇▇ Institution for Rehabilitation — ▇▇▇▇▇▇▇ West		Essex		R0706
Newark ▇▇▇▇ Israel Medical Center		Essex		H0707
St. Barnabas Medical Center		Essex		▇▇▇▇▇
▇▇. ▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
St. Michael’▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
UMDNJ — University Hospital		Essex		H0712
VA New Jersey Health care System — ▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ Memorial Hospitals — ▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇▇▇ Memorial Hospital		Gloucester		▇▇▇▇▇
▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇ Hospital		▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
Liberty Health Care System — ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
Liberty Health Care System — ▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
Liberty Health Care System — ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
Palisades Medical Center — New York Presbyterian Health Care System		▇▇▇▇▇▇		H0907
St. Mary’s Hospital		▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
Senator ▇▇▇▇▇▇▇ ▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇-Psychiatric Hospital		Hunterdon		P1002
Capital Health System — Fuld Campus		▇▇▇▇▇▇		H1101

Exhibit 10.6.9

Hospital Name		County Location		Codes
Capital Health System — ▇▇▇▇▇▇ Campus		▇▇▇▇▇▇		H1102
University Medical Center at Princeton		▇▇▇▇▇▇		H1103
▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ University Hospital At ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
▇▇. ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
St. ▇▇▇▇▇▇▇▇ Rehabilitation center		▇▇▇▇▇▇		R1106
Trenton Psychiatric Hospital		▇▇▇▇▇▇		P1107
▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
Raritan ▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ — ▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
Raritan Bay Medical Center — Perth Amboy		Middlesex		H1203
▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ University Hospital — ▇▇▇ ▇▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇. ▇▇▇▇▇’s University Hospital		Middlesex		H1205
JFK ▇▇▇▇▇▇▇ Rehabilitation Hospital		Middlesex		R1206
University Behavioral HealthCare		Middlesex		P1207
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
CentraState Healthcare System		Monmouth		H1302
Jersey Shore ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
Monmouth Medical Center		Monmouth		H1304
▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
HEALTHSOUTH Rehabilitation Hospital at ▇▇▇▇▇▇ ▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ Memorial Hospital		▇▇▇▇▇▇		H1401
Morristown Memorial Hospital		▇▇▇▇▇▇		H1402
St. Clare’s Health Services — Denville		▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇▇▇ ▇▇▇▇ Psychiatric Hospital		▇▇▇▇▇▇		P1404
▇▇▇▇▇▇▇ Institute for Rehabilitation Corporation-▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
▇▇. ▇▇▇▇▇’s Hospital ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
Community Medical Center		Ocean		H1501
▇▇▇▇▇▇▇ Medical Center		Ocean		H1502
Meridian Health Ocean ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ Hospital		Ocean		H1504
HEALTHSOUTH Rehabilitation Hospital of Toms River		Ocean		H1505

Exhibit 10.6.9

Hospital Name		County Location		Codes
St. Barnabas Behavioral Health Network		Ocean		P1506
▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇		▇▇▇▇▇
Passaic ▇▇▇▇ Israel Regional Health Network		Passaic		H1602
St. Joseph’s Hospital and Medical Center — ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇		▇▇▇▇▇
St. ▇▇▇▇▇▇’▇ ▇▇▇▇▇ Hospital		Passaic		H1604
St. Mary’s Hospital Passaic		Passaic		H1605
South Jersey Healthcare — ▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
The Memorial Hospital of Salem county		Salem		H1702
Carrier Clinic		Somerset		P1801
The ▇▇▇▇▇▇▇ School and Hospital		Somerset		▇▇▇▇▇
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
VA New Jersey Health Care System ▇▇▇▇▇		Somerset		V1804
▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
St. Clare’s Hospital /Sussex		Sussex		H1902
Muhlenburg Regional ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
Overlook Hospital		Union		H2002
▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ University Hospital at ▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
Trinitas Hospital ▇▇▇▇▇▇▇▇▇▇ Street Campus		Union		▇▇▇▇▇
▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
Children’s Specialized Hospital		Union		R2006
▇▇▇▇▇▇▇▇ Specialized Hospital		Union		S2007
Summit Hospital		Union		P2008
Hackettstown Community Hospital		▇▇▇▇▇▇		H2101
▇▇▇▇▇▇ Hospital		▇▇▇▇▇▇		H2102

Exhibit 10.6.9

HOSPITAL NAME		COUNTY LOCATION		CODES
Ancora Psychiatric Hospital		Atlantic		P0101
Atlantic City Medical Center — City Division		Atlantic		H0102
Atlantic City Medical Center — Mainland Division		Atlantic		H0103
Bacharach Institute for Rehabilitation		Atlantic		▇▇▇▇▇
▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇▇ Memorial Hospital		Atlantic		R0106
Bergen Regional Medical Center		Bergen		H0201
Christian Health Care Center		Bergen		P0202
Englewood Hospital and Medical Center		Bergen		H0203
Hackensack University Medical Center		Bergen		H0204
Holy Name Hospital		Bergen		H0205
▇▇▇▇▇▇▇ Institution for Rehabilitation — ▇▇▇▇▇▇▇ North		Bergen		R0206
Pascack Valley Hospital		Bergen		H0207
Valley Health System — The Valley Hospital		Bergen		▇▇▇▇▇
▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ Heart and Lung Center		Burlington		S0302
Hampton Hospital		Burlington		P0303
Mediplex Rehabilitation Hospital		Burlington		R0304
Virtua Health — ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
Virtua Health — ▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
Voorhees Pediatric Rehabilitation Hospital		Burlington		R0307
The ▇▇▇▇▇▇ Health System		Camden		H0401
▇▇▇▇▇▇▇ Memorial Hospital- ▇▇▇▇▇▇ ▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇- ▇▇▇▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ Health System-Our Lady of ▇▇▇▇▇▇▇ Medical Center		Camden		H0404
Virtua West Jersey Hospital — Berlin		Camden		▇▇▇▇▇
▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇ Hospital — Voorhees		Camden		H0406
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Memorial Hospital		Cape May		▇▇▇▇▇
▇▇▇▇▇ ▇▇▇▇▇▇ Health System- ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇		▇▇▇▇▇

Exhibit 10.6.9

HOSPITAL NAME		COUNTY LOCATION		CODES
South Jersey Health system South Jersey Hospital - Vineland		Cumberland		▇▇▇▇▇
▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
Columbus Hospital		Essex		▇▇▇▇▇
▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
Hospital Center at Orange		Essex		H0704
▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ Institution for Rehabilitation — ▇▇▇▇▇▇▇ East		Essex		R0706
▇▇▇▇▇▇▇ Institution for Rehabilitation — ▇▇▇▇▇▇▇ West		Essex		R0707
Newark ▇▇▇▇ Israel Medical Center		Essex		H0708
St. Barnabas Medical Center		Essex		▇▇▇▇▇
▇▇. ▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
St. Michael’▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
UMDNJ — University Hospital		Essex		H0713
VA New Jersey Health care System — East Orange		Essex		V0714
▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ Memorial Hospitals — ▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇▇▇ Memorial Hospital		Gloucester		▇▇▇▇▇
▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇ Hospital		▇▇▇▇▇▇		H0902
Liberty Health Care System — ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
Liberty Health Care System — ▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
Liberty Health Care System — ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
Palisades Medical Center — New York Presbyterian Health Care System		▇▇▇▇▇▇		H0906
St. Mary’s Hospital		▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
Senator ▇▇▇▇▇▇▇ ▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇-Psychiatric Hospital		Hunterdon		P1002
Capital Health System — Fuld Campus		▇▇▇▇▇▇		H1101
Capital Health System — ▇▇▇▇▇▇ Campus		▇▇▇▇▇▇		H1102

Exhibit 10.6.9

HOSPITAL NAME		COUNTY LOCATION		CODES
The Medical Center at Princeton		▇▇▇▇▇▇		H1103
▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ University Hospital ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
▇▇. ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
St. ▇▇▇▇▇▇▇▇ Rehabilitation center		▇▇▇▇▇▇		R1106
Trenton Psychiatric Hospital		▇▇▇▇▇▇		P1107
▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
Raritan ▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ — ▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
Raritan Bay Medical Center — Perth Amboy		Middlesex		H1203
▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇ University Hospital — ▇▇▇ ▇▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇. ▇▇▇▇▇’s University Hospital		Middlesex		H1205
JFK ▇▇▇▇▇▇▇ Rehabilitation Hospital		Middlesex		R1206
University Behavioral HealthCare		Middlesex		P1207
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
CentraState Healthcare System		Monmouth		H1302
Jersey Shore ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
Monmouth Medical Center		Monmouth		H1304
▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
HEALTHSOUTH Rehabilitation Hospital at ▇▇▇▇▇▇ ▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇ Memorial Hospital		▇▇▇▇▇▇		H1401
Morristown Memorial Hospital		▇▇▇▇▇▇		H1402
St. Clare’s Health Services — Denville		▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇▇▇ ▇▇▇▇ Psychiatric Hospital		▇▇▇▇▇▇		P1404
▇▇▇▇▇▇▇ Rehabilitation Corporation- ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
▇▇. ▇▇▇▇▇’s Health Services Boonton		▇▇▇▇▇▇		P1406
St Barnabas Health Care System Community Medical Center		Ocean		H1501
St Barnabas Health Care System ▇▇▇▇▇▇ Medical Center		Ocean		H1502
Meridian Health Ocean ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ Hospital		Ocean		H1504
HEALTHSOUTH Rehabilitation Hospital of Toms River		Ocean		H1505
St. Barnabas Behavioral Health Network		Ocean		P1506
▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇		▇▇▇▇▇

Exhibit 10.6.9

HOSPITAL NAME		COUNTY LOCATION		CODES
▇▇▇▇ Israel Hospital		Passaic		H1602
St. Joseph’s Hospital and Medical Center — ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇▇		▇▇▇▇▇
St. ▇▇▇▇▇▇’▇ ▇▇▇▇▇ Hospital		Passaic		H1604
St. Mary’s Hospital Passaic		Passaic		H1605
The General Hospital Center At Passaic		Passaic		H1606
South Jersey Healthcare — ▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
The Memorial Hospital of Salem county		Salem		H1702
Carrier Clinic		Somerset		P1801
The ▇▇▇▇▇▇▇ School and Hospital		Somerset		▇▇▇▇▇
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
VA New Jersey Health Care System ▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇▇		▇▇▇▇▇
St. Clare’s Health Services/Sussex		Sussex		H1902
Solaris Health System — Muhlenburg Regional ▇▇▇▇▇▇▇ ▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
▇▇▇▇▇▇▇▇ Health System Overlook Hospital		Union		▇▇▇▇▇
▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇		▇▇▇▇▇		▇▇▇▇▇
RJW Health Systems Children’s Specialized Hospital		Union		H2003
▇▇▇▇▇▇▇▇ Specialized Hospital		Union		S2007
Summit Hospital		Union		P2008
Hackettstown Community Hospital		▇▇▇▇▇▇		H2101
▇▇▇▇▇▇ Hospital		▇▇▇▇▇▇		H2102

Exhibit 10.6.9

B — Report Specifications

1) Prepare a separate geographic accessibility analysis for each county. Restrict provider groups to service area equal to county. Separate analyses are required for each of the following:

		Beneficiaries - Include all AFDC, DYFS, NJ FamilyCare, SSI-ABD
Provider Type		All Ages		Children under 21		Adults 21 and up
Adult PCPs (FP, FP, IM OB/GYN-women only						Page Codes 1-9
Pediatric PCPs (FP, Ped., GP)
General Dentists		Page Codes 1-9
Hospitals		Page Codes 1-10 & 12
Blood Drawing Centers and Labs that Draw Blood		Page Codes 11 & 12

2) See Article 4.8.8 for standards A and B for each provider type. For example, eligibles living in urban areas should have two PCPs within six miles. Mileage should be calculated on an estimated driving distance basis.

3). Each of the analyses should consist of the pages indicated above.

Page		Access
Code		Standard		Description
1		na*		This cover page of each report includes plan name, county beneficiary group and date.
2		na*		This page uses a graph to illustrate the percentage of beneficiaries who have access to a group of providers at various distances. It includes a table showing the average distances to the nearest choices of one, two, three, four and five providers.
3		na*		This page shows, by zip code, the average distance for beneficiaries to two providers and the percentage of beneficiaries having two providers within 2, 6, 10 and 15 miles
4		A		This page shows the number of providers, the number of beneficiaries with access to two providers and the average distance to up to five providers for beneficiaries with access. It also analyzes beneficiary accessibility in ten key cities.
5		A		This page shows, by zip code, the number and percentage of beneficiaries who do not have access to a choice of two providers and the average distance to one and two providers.
6		B		This page shows the number of providers the number of beneficiaries with access to one provider and the average distance to up to five providers for beneficiaries with access. It also analyzes beneficiary

Exhibit 10.6.9

Page		Access
Code		Standard		Description
				accessibility in ten key cities.
7		B		This page shows, by zip code, the number and percentage of beneficiaries who do not have access to one provider and their average distance to one provider.
8		na*		This includes documentation about the report and its data sources
9		A		This county map shows beneficiary locations for those who do not have access to two providers. Use 2 point black circles for beneficiaries.
10		na*		This county map shows provider locations. Use 12 point light ▇▇▇▇ circles for individual and 12 point black triangles for multiple provider locations.
11		na*		This county map shows all beneficiaries and a five mile radius circle around each provider location. The map should show only “Radius 1” which should be transparent. Use provider and beneficiary symbol specifications from page codes 9 and 10.
12		na*		This should be a hard copy of the geocoded provider file, which must include name, specialty/type, address, zip code, individual capacity (where applicable), geographic coordinates and geocoding method return code.

4) Save to dBASE file the geocoded provider file according to the specifications indicated in Figure 1.

Figure 1

Field Name		Description
NAME1		Last name for individual providers (include suffix, e.g., Jr. Sr.) Entire name for institution
NAME2		First name and middle initial with period for individuals
ADDRESS1		Street number first then street name where medical care is actually provided
ADDRESS2		Additional information (e.g., suite #, building)
STDCITY		Standard city name according to geocoder output field
STATE		State
ZIP		Full zip codes in character or text format to show leading zeros
SPECIALTY		Primary specialty only for individual providers Provider type for institutions
LONGITUDE		Geocoded Longitude
LATITUDE		Geocoded Latitude
GEOMETHOD		Return codes from geocoder
CAPACITY		Individual capacity used for access analysis when applicable

Report specifications, calculations and supporting data files for geographic analysis reports submitted to DMAHS must be retained in accordance with 45 CFR. Part 74 and made available on request

Exhibit 10.6.9

A.7.1.A CERTIFICAION OF ENROLLMENT INFORMATION RELATING TO PAYMENT UNDER THE Medicaid/NJ FAMILYCARE PROGRAM.

Exhibit 10.6.9

 A

(Sample Certification Form)

This certification includes the State of New Jersey’s proposed language for data submission certification for the New Jersey Medicaid/NJ FamilyCare Program.

CERTIFICATION OF ENROLLMENT INFORMATION RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM

CERTIFICATION

Pursuant to the contract(s) between the Department of Human services and the (name of managed care organization (MCO), provider certifies that; the business entity named on this form is a qualified provider enrolled with and authorized to participate in the New Jersey Medical Assistance Program as an MCO designated as Plan number (insert Plan identification number(s) here). (Name of MCO) acknowledges that if payment is based on enrollment data, Federal regulations at 42 CFR 438.600 (▇▇.▇▇.) require that the data submitted must be certified by a Chief Financial Officer, Chief Executive Officer, or a person who reports directly to and who is authorized to sign for the Chief Financial Officer or Chief Executive Officer.

(Name of MCO) hereby requests payment from the New Jersey Medical Assistance Program under contracts based on enrollment data submitted and in doing so makes the following certification to the Department of Human Services (DHS) as required by the Federal regulations at 42 CFR 438.600 (▇▇.▇▇.)

(Name of MCO) has reported to the DHS for the month of (indicate month and year) all new enrollments, disenrollments, and any changes in the enrollee’s status. (Name of MCO) has reviewed the monthly membership report for the month of (indicate month and year) and I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person who Reports Directly to and Who is Authorized to Sign for Chief Financial Officer or Chief Executive Officer) attest that based on best knowledge, information, and belief as of the date indicated below, all information submitted to DHS in this report is accurate, complete, and truthful, and I hereby certify that NO MATERIAL FACT HAS BEEN OMITTED FROM THIS FORM AND/OR THE DATA SUBMISSION.

Exhibit 10.6.9

I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person who Reports Directly to and Who is Authorized to Sign for Chief Financial Officer or Chief Executive Officer), ACKNOWLEDGE THAT THE INFORMATION DESCRIBED ABOVE MAY DIRECTLY AFFECT THE CALCULATION OF PAYMENTS TO (Name of MCO). I UNDERSTAND THAT I MUST COMPLY WITH ALL APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF THIS SUBMISSION.

		(INDICATE NAME AND TILTE
		CFO, CEO OR DELGATE))
		On behalf of
		(INDICATE NAME OF BUSINESS ENTITY)
		DATE

Exhibit 10.6.9

A.7.1.B CERTIFICATION OF ECOUNTER INFORMATION RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM

Exhibit 10.6.9

 B

(Sample Certification Form)

This certification includes the State of New Jersey’s proposed language for data submission certification for the New Jersey Medicaid/NJ FamilyCare Program.

CERTIFICATION OF ENCOUNTER INFORMATION RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM

CERTIFICATION

Pursuant to the contract(s) between the Department of Human Services and the (name of managed care organization (MCO), provider certifies that; the business entity named on this form is a qualified provider enrolled with and authorized to participate in the New Jersey Medical Assistance Program as an MCO designated as Plan number (insert Plan identification number(s) here). (Name of MCO) acknowledges that if payment is based on encounter data, Federal regulations at 42 CFR 438.600 (▇▇.▇▇.) require that the data submitted must be certified by a Chief Financial Officer, Chief Executive Officer, or a person who reports directly to and who is authorized to sign for the Chief Financial Officer or Chief Executive Officer.

(Name of MCO) hereby requests payment from the New Jersey Medical Assistance Program under contracts based on encounter data submitted and in doing so makes the following certification to the Department of Human Services (DHS) as required by the Federal regulations at 42 CFR 438.600 (▇▇.▇▇.)

(Name of MCO) has reported to the DHS for the month of (indicate month and year) all new encounters, (indicate type of data — inpatient hospital, outpatient hospital, physician, etc.). (Name of MCO) has reviewed the encounter data for the month of (indicate month and year) and I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person who Reports Directly to and Who is Authorized to Sign for Chief Financial Officer or Chief Executive Officer) attest that based on best knowledge, information, and belief as of the date indicated below, all information submitted to DHS in this report is accurate, complete, and truthful, and I hereby certify that NO MATERIAL FACT HAS BEEN OMITTED FROM THIS FORM AND/OR THE DATA SUBMISSION.

Exhibit 10.6.9

I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person who Reports Directly to and Who is Authorized to Sign for Chief Financial Officer or Chief Executive Officer), ACKNOWLEDGE THAT THE INFORMATION DESCRIBED ABOVE MAY DIRECTLY AFFECT THE CALCULATION OF PAYMENTS TO (Name of MCO). I UNDERSTAND THAT I MUST COMPLY WITH ALL APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF THIS SUBMISSION.

		(INDICATE NAME AND TILTE
		CFO, CEO OR DELGATE))
		On behalf of
		(INDICATE NAME OF BUSINESS ENTITY)
		DATE

Exhibit 10.6.9

A.7.1.C CERTIFICATION OF ANY INFORMATION REQUIRED BY THE STATE AND CONTAINED IN CONTRACTS, PROPOSALS, AND RELATED DOCUMENTS RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM.

Exhibit 10.6.9

 C

(Sample Certification Form)

This certification includes the State of New Jersey’s proposed language for data submission certification for the New Jersey Medicaid/NJ FamilyCare Program.

CERTIFICATION OF ANY INFORMATION REQUIRED BY THE STATE AND CONTAINED IN CONTRACTS, PROPOSALS, AND RELATED DOCUMENTS RELATING TO PAYMENT UNDER THE MEDICAID/NJ FAMILYCARE PROGRAM

CERTIFICATION

Pursuant to the contract(s) between the Department of Human services and the (name of managed care organization (MCO), provider certifies that; the business entity named on this form is a qualified provider enrolled with and authorized to participate in the New Jersey Medical Assistance Program as an MCO designated as Plan number (insert Plan identification number(s) here). (Name of MCO) acknowledges that if payment is based on any information required by the State and contained in contracts, proposals, and related documents, Federal regulations at 42 CFR 438.600 (▇▇.▇▇.) require that the data submitted must be certified by a Chief Financial Officer, Chief Executive Officer, or a person who reports directly to and who is authorized to sign for the Chief Financial Officer or Chief Executive Officer.

(Name of MCO) hereby requests payment from the New Jersey Medical Assistance Program under contracts based on any information required by the State and contained in contracts, proposals, and related documents submitted and in doing so makes the following certification to the Department of Human Services (DHS) as required by the Federal regulations at 42 CFR 438.600 (▇▇.▇▇.)

(Name of MCO) has reported to the DHS for the period of (indicate dates) all information required by the State and contained in contracts, proposals, and related documents submitted. (Name of MCO) has reviewed the monthly membership report for the period of (indicate dates) and I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person who Reports Directly to and Who is Authorized to Sign for Chief Financial Officer or Chief Executive Officer) attest that based on best knowledge, information, and belief as of the date indicated below, all information submitted to DHS in this report is

Exhibit 10.6.9

accurate, complete, and truthful, and I hereby certify that NO MATERIAL FACT HAS BEEN OMITTED FROM THIS FORM AND/OR THE DATA SUBMISSION.

I, (enter Name of Chief Financial Officer, Chief Executive Officer or Name of Person who Reports Directly to and Who is Authorized to Sign for Chief Financial Officer or Chief Executive Officer), ACKNOWLEDGE THAT THE INFORMATION DESCRIBED ABOVE MAY DIRECTLY AFFECT THE CALCULATION OF PAYMENTS TO (Name of MCO). I UNDERSTAND THAT I MUST COMPLY WITH ALL APPLICABLE FEDERAL AND STATE LAWS FOR ANY FALSE CLAIMS, STATEMENTS, OR DOCUMENTS, OR CONCEALMENT OF A MATERIAL FACT. I HAVE READ AND AM FAMILIAR WITH THE CONTENTS OF THIS SUBMISSION.

		(INDICATE NAME AND TILTE
		CFO, CEO OR DELGATE))
		On behalf of
		(INDICATE NAME OF BUSINESS ENTITY)
		DATE

Exhibit 10.6.9

A.7.1.E. Certification of HIV/AIDS/Hemophilia

Exhibit 10.6.9

E.

HIV/AIDS/Hemophilia

		Month of Certification
		Run Date

I,                                          , hereby certify on behalf of                                                             
Name of Medical Director                                                            Name of HMO

that                                         , Medicaid ID number                                                               

           Name of Member

a member of said HMO, has been diagnosed by his/her treating physician with and/or is being treated for HIV or AIDS or Hemophilia requiring Factors VIII or IX (circle any that apply). If including more than one member, you may attach a written list of members specifying the diagnosis of each individual.

The number of members with HIV is                     ; AIDS                     ; Factor VIII                    ; Factor IX                      I certify that the foregoing statements are true, and attest that based on best knowledge, information, and belief as of the date indicated below, all information submitted to DMAHS is accurate, complete and truthful, and certify that no material fact has been omitted from this form. I am aware that if any foregoing statements made by me are willfully false,                                         , may be subject to the imposition