-
B.24 – Current External Quality Review Organization & Copy
of CAP
-
ME
RC
Y C
AR
E P
LAN
AC
UTE
A
HC
CC
S O
PE
RA
TIO
NA
L A
ND
FIN
AN
CIA
L R
EV
IEW
CO
NTR
AC
T Y
EA
R E
ND
ING
200
9
Mar
ch 1
6, 2
009-
Mar
ch 1
8, 2
009
Con
duct
ed b
y th
e A
rizon
a H
ealth
Car
e C
ost C
onta
inm
ent S
yste
m
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
1
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
2
TA
BLE
OF
CO
NTE
NTS
INTR
OD
UC
TIO
N...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
....3
STA
FF P
AR
TIC
IPA
TIO
N...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
...4
SC
OR
ING
MET
HO
DO
LOG
Y...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.11
QU
ALI
TATI
VE
SU
MM
AR
Y O
F FI
ND
ING
S...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.....1
2
QU
AN
TITA
TIV
E S
UM
MA
RY
OF
FIN
DIN
GS
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.....1
5
ME
MB
ER
INFO
RM
ATI
ON
AN
D A
DM
INIS
TRA
TIV
E S
ER
VIC
ES
......
......
......
......
......
......
......
......
......
......
......
......
......
......
....2
4
CA
SE
MA
NAG
EM
EN
T....
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
....3
3
ME
DIC
AL
MAN
AG
EM
ENT.
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.45
AU
THO
RIZ
ATI
ON
AN
D G
RIE
VA
NC
E S
YS
TEM
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.....6
4
MA
TER
NA
L A
ND
CH
ILD
HE
ALT
H A
ND
EP
SD
T...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.....1
07
QU
ALI
TY M
ANA
GE
MEN
T...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
...12
4
DE
LIV
ER
Y S
YS
TEM
S A
ND
PR
OVI
DE
R R
ELA
TIO
NS
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.....1
65
FIN
AN
CIA
L M
ANA
GE
MEN
T...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
173
CLA
IMS
AN
D IN
FOR
MA
TIO
N S
YS
TEM
S...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
...18
0
EN
CO
UN
TER
S A
ND
RE
INS
UR
ANC
E...
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
..189
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
2
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
3
INTR
OD
UC
TIO
N
The
Ariz
ona
Hea
lth C
are
Cos
t Con
tain
men
t Sys
tem
(AH
CC
CS
) has
ser
ved
Ariz
ona’
s m
ost n
eedy
sin
ce 1
982.
The
A
genc
y’s
visi
on is
“to
shap
e to
mor
row
’s m
anag
ed c
are
syst
em w
ith to
day’
s ex
perie
nce,
qua
lity
and
inno
vatio
n.” A
s a
com
pone
nt o
f ach
ievi
ng th
is v
isio
n, A
HC
CC
S re
gula
rly re
view
s its
Con
tract
ors
to e
nsur
e th
at th
eir o
pera
tions
, fin
ance
s an
d pe
rform
ance
are
in c
ompl
ianc
e w
ith F
eder
al a
nd S
tate
law
; rul
es a
nd re
gula
tions
; and
the
AH
CC
CS
Con
tract
. The
re
view
ers
use
a pr
oces
s ap
prov
ed b
y th
e C
ente
rs fo
r Med
icar
e an
d M
edic
aid
Ser
vice
s (C
MS
) bas
ed u
pon
the
term
s of
th
e co
ntra
ct w
ith A
HC
CC
S.
The
prim
ary
obje
ctiv
es o
f the
Mer
cy C
are
Pla
n C
YE
09 O
pera
tiona
l and
Fin
anci
al R
evie
w a
re to
:
D
eter
min
e if
the
Con
tract
or s
atis
fact
orily
mee
ts A
HC
CC
S’ r
equi
rem
ents
as
spec
ified
in th
e A
cute
Car
e co
ntra
ct
YH
09-0
001,
AH
CC
CS
pol
icie
s an
d th
e A
rizon
a A
dmin
istra
tive
Cod
e.
In
crea
se A
HC
CC
S k
now
ledg
e of
the
Con
tract
or’s
ope
ratio
nal a
nd fi
nanc
ial p
roce
dure
s.
P
rovi
de te
chni
cal a
ssis
tanc
e an
d id
entif
y ar
eas
whe
re im
prov
emen
ts c
an b
e m
ade;
as
wel
l as
iden
tifyi
ng a
reas
of
note
wor
thy
perfo
rman
ce a
nd a
ccom
plis
hmen
ts.
R
evie
w p
rogr
ess
in im
plem
entin
g re
com
men
datio
ns m
ade
durin
g pr
ior R
evie
ws.
Det
erm
ine
if th
e C
ontra
ctor
is in
com
plia
nce
with
its
own
polic
ies
and
to e
valu
ate
the
effe
ctiv
enes
s of
thos
e po
licie
s an
d pr
oced
ures
.
Per
form
Con
tract
or o
vers
ight
as
requ
ired
by th
e C
MS
in a
ccor
danc
e w
ith A
HC
CC
S’ 1
115
wai
ver.
P
rovi
de in
form
atio
n to
an
Ext
erna
l Qua
lity
Rev
iew
Org
aniz
atio
n (E
QR
O) f
or it
s us
e as
des
crib
ed in
42
CFR
43
8.36
4.
A c
opy
of th
is re
port
was
pro
vide
d to
the
Con
tract
or fo
r rev
iew
on
June
3, 2
009.
The
Con
tract
or is
giv
en a
per
iod
of tw
o w
eeks
in w
hich
to fi
le a
cha
lleng
e to
any
find
ings
it d
oes
not f
eel a
re a
ccur
ate
base
d on
the
evid
ence
ava
ilabl
e at
the
time
of re
view
. A
fter t
his
chal
leng
e pe
riod,
the
Fina
l Rep
ort w
as is
sued
to th
e C
ontra
ctor
on
June
25,
200
9. U
pon
issu
ance
of t
he F
inal
R
epor
t, th
e C
ontra
ctor
is re
quire
d to
mai
ntai
n th
e co
nfid
entia
lity
of th
e in
form
atio
n, in
clud
ing
the
stan
dard
crit
eria
and
fin
ding
s of
the
Rev
iew
Tea
m u
ntil
such
tim
e as
AH
CC
CS
det
erm
ines
; in
orde
r to
mai
ntai
n th
e in
tegr
ity o
f the
pro
cess
unt
il al
l Con
tract
ors
have
bee
n re
view
ed.
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
3
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
4
STA
FF P
AR
TIC
IPA
TIO
N
The
CY
E09
AH
CC
CS
Rev
iew
Tea
m in
clud
ed e
mpl
oyee
s of
the
Div
isio
n of
Hea
lth C
are
Man
agem
ent (
DH
CM
) in:
Acu
te
Car
e, R
eins
uran
ce, D
ata
Ana
lysi
s an
d R
esea
rch,
Med
ical
Man
agem
ent,
Clin
ical
Qua
lity
Man
agem
ent;
and
the
Offi
ce o
f A
dmin
istra
tive
Lega
l Ser
vice
s (O
ALS
). A
HC
CC
S S
TAFF
PA
RTI
CIP
ATI
ON
N
AM
E
TITL
E
ME
MB
ER
INFO
RM
ATI
ON
AN
D A
DM
INIS
TRA
TIV
E
SE
RV
ICE
S
Eliz
abet
h S
tack
fleth
Jo
hn B
lack
P
.J. S
choe
nste
ne
Rod
d M
as
Car
la K
ot
Mar
y S
teig
erw
ald
Com
plia
nce
Offi
cer
Com
plia
nce
Offi
cer
Com
plia
nce
Offi
cer
Acu
te O
pera
tions
Man
ager
H
CG
Ass
ista
nt D
irect
or
HC
G A
ssis
tant
Dire
ctor
CA
SE
MA
NA
GE
ME
NT
Car
ol S
ande
rs
John
Bla
ck
Cas
e M
anag
er
Com
plia
nce
Offi
cer
ME
DIC
AL
MA
NA
GE
ME
NT
Lind
a V
rabe
l M
aure
en W
ade
Eliz
abet
h S
tack
fleth
R
odd
Mas
C
arla
Kot
M
ary
Ste
iger
wal
d
Med
ial M
anag
emen
t Spe
cial
ist
Med
ical
Man
agem
ent M
anag
er
Acu
te C
ompl
ianc
e O
ffice
r A
cute
Ope
ratio
ns M
anag
er
HC
G A
ssis
tant
Dire
ctor
H
CG
Ass
ista
nt D
irect
or
A
UTH
OR
IZA
TIO
N A
ND
GR
IEV
AN
CE
SY
STE
M
Eliz
abet
h S
tack
fleth
Jo
hn B
lack
R
odd
Mas
M
aure
en W
ade
Lind
a V
rabe
l
Com
plia
nce
Offi
cer
Com
plia
nce
Offi
cer
Acu
te O
pera
tions
Man
ager
M
edic
al M
anag
emen
t Man
ager
M
edic
al M
anag
emen
t Spe
cial
ist
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
4
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
5
AH
CC
CS
STA
FF P
AR
TIC
IPA
TIO
N
NA
ME
TI
TLE
Jo
seph
Rui
z C
arla
Kot
M
ary
Ste
iger
wal
d
Hea
ring
Offi
cer
HC
G A
ssis
tant
Dire
ctor
H
CG
Ass
ista
nt D
irect
or
M
ATE
RN
AL
AN
D C
HIL
D H
EA
LTH
AN
D E
PSD
T G
loria
Nav
arro
-V
alve
rde
Con
nie
Willi
ams
Kim
Elli
ott
Eliz
abet
h S
tack
fleth
R
odd
Mas
C
arla
Kot
M
ary
Ste
iger
wal
d
MC
H S
peci
alis
t S
uper
viso
r, C
QM
M
anag
er, C
QM
A
cute
Com
plia
nce
Offi
cer
Acu
te O
pera
tions
Man
ager
H
CG
Ass
ista
nt D
irect
or
HC
G A
ssis
tant
Dire
ctor
CLI
NIC
AL
QU
ALI
TY M
AN
AG
EM
ENT
C
harle
s Le
Van
cier
R
oche
lle T
igne
r C
onni
e W
illiam
s S
usan
Lua
rk
Kim
Elli
ott
Ale
xand
ra O
’Han
non
Eliz
abet
h S
tack
fleth
R
odd
Mas
C
arla
Kot
M
ary
Ste
iger
wal
d
Spe
cial
ist,
CQ
M
Qua
lity
Impr
ovem
ent M
anag
er
Sup
ervi
sor,
CQ
M
Sup
ervi
sor,
CQ
M
Man
ager
, CQ
M
Beh
avio
ral H
ealth
Man
ager
A
cute
Com
plia
nce
Offi
cer
Acu
te O
pera
tions
Man
ager
H
CG
Ass
ista
nt D
irect
or
HC
G A
ssis
tant
Dire
ctor
DE
LIV
ER
Y S
YS
TEM
S A
ND
PR
OVI
DE
R R
ELA
TIO
NS
E
lizab
eth
Sta
ckfle
th
John
Bla
ck
P.J
. Sch
oens
tene
R
odd
Mas
C
arla
Kot
Com
plia
nce
Offi
cer
Com
plia
nce
Offi
cer
Com
plia
nce
Offi
cer
Acu
te C
are
Ope
ratio
ns
Man
ager
H
CG
Ass
ista
nt D
irect
or
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
5
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
6
AH
CC
CS
STA
FF P
AR
TIC
IPA
TIO
N
NA
ME
TI
TLE
M
ary
Ste
iger
wal
d H
CG
Ass
ista
nt D
irect
or
C
LAIM
S A
ND
INFO
RM
ATI
ON
SY
STE
MS
D
avid
Bjo
rn
Lori
Pet
re
Com
plia
nce
Offi
cer
Dat
a &
Res
earc
h M
anag
er
E
NC
OU
NTE
RS
AN
D R
EIN
SU
RA
NC
E
Bre
nt R
atte
rree
Pat
ricia
Pee
rs
Enc
ount
er M
anag
er
Rei
nsur
ance
Sup
ervi
sor
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
6
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
7
Mer
cy C
are
Plan
43
50 E
. Cot
ton
Cen
ter B
lvd.
B
uild
ing
D
Pho
enix
, AZ
850
40
Mer
cy C
are
Pla
n ha
s be
en c
ontra
cted
with
AH
CC
CS
sin
ce 1
983
for t
he a
cute
pro
gram
and
ser
ves
elig
ible
enr
olle
d m
embe
r in
the
follo
win
g G
eogr
aphi
c S
ervi
ce A
reas
(GSA
) by
prog
ram
: A
CU
TE
GS
A 1
4 G
SA
13
GS
A 1
0
Coc
hise
G
raha
m
Gre
enle
e M
aric
opa
Pim
a (c
appe
d)
CO
NTR
AC
TOR
STA
FF P
AR
TIC
IPA
TIO
N
NA
ME
TI
TLE
M
EM
BE
R IN
FOR
MA
TIO
N A
ND
AD
MIN
ISTR
ATI
VE
S
ER
VIC
ES
C
athy
Wal
dbilli
g B
rian
Hor
gesh
imer
K
ristin
e N
ewm
an
Dire
ctor
Mem
ber a
nd E
nrol
lmen
t S
ervi
ces
Com
plia
nce
Offi
cer
Com
plia
nce
Man
ager
C
AS
E M
AN
AG
EM
EN
T K
ristin
e N
ewm
an
Bria
n H
orge
shim
er
Pat
ti S
imps
on
Com
plia
nce
Man
ager
C
ompl
ianc
e O
ffice
r C
ompl
ianc
e O
ffice
r, Sc
halle
r A
nder
son
ME
DIC
AL
MA
NA
GE
ME
NT
Gin
a C
onfli
tti, M
D
Sue
Ben
edet
ti In
terim
Med
ial D
irect
or
VP
, Med
ical
Man
agem
ent
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
7
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
8
CO
NTR
AC
TOR
STA
FF P
AR
TIC
IPA
TIO
N
NA
ME
TI
TLE
Ju
man
Abj
ubar
a S
haun
a S
ly
Faye
Cox
B
rian
Hor
gesh
imer
K
ristin
e N
ewm
an
VP
, QM
& S
peci
al P
rogr
ams
Prio
r Aut
horiz
atio
n C
linic
al
Sup
ervi
sor
Com
plai
nt &
App
eal M
anag
er
Com
plia
nce
Offi
cer
Com
plia
nce
Man
ager
A
UTH
OR
IZA
TIO
N A
ND
GR
IEV
AN
CE
SY
STE
M
Gin
a C
onfli
tti, M
D
Sue
Ben
edet
ti Ju
man
Abj
ubar
a S
haun
a S
ly
Faye
Cox
B
rian
Hor
gesh
imer
K
ristin
e N
ewm
an
Inte
rim M
edia
l Dire
ctor
V
P, M
edic
al M
anag
emen
t V
P, Q
M &
Spe
cial
Pro
gram
s P
rior A
utho
rizat
ion
Clin
ical
S
uper
viso
r C
ompl
aint
& A
ppea
l Man
ager
C
ompl
ianc
e O
ffice
r C
ompl
ianc
e M
anag
er
MA
TER
NA
L A
ND
CH
ILD
HE
ALT
H A
ND
EP
SDT
Gin
a C
onfli
tti, M
D
Sue
Ben
edet
ti Ju
man
Abj
ubar
a D
an J
anse
n C
indy
Joh
nson
N
issa
And
erso
n Ta
d G
ary
Arle
ne W
arre
n Te
rri W
olfa
ng
Kris
tine
New
man
B
rian
Hor
gesh
imer
Inte
rim M
edic
al D
irect
or
VP
, Med
ical
Man
agem
ent
VP
, QM
& S
peci
al P
rogr
ams
Dire
ctor
, Pre
vent
ion
& W
elln
ess
Man
ager
, Cas
e M
anag
emen
t E
PS
DT
Coo
rdin
ator
B
ehav
iora
l Hea
lth C
oord
inat
or
QM
Man
ager
C
rede
ntia
ling
Ope
ratio
ns M
gr
Com
plia
nce
Man
ager
C
ompl
ianc
e O
ffice
r
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
8
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
9
CO
NTR
AC
TOR
STA
FF P
AR
TIC
IPA
TIO
N
NA
ME
TI
TLE
P
atti
Sim
pson
Com
plia
nce
Offi
cer,
Scha
ller
And
erso
n
CLI
NIC
AL
QU
ALI
TY M
AN
AG
EM
ENT
G
ina
Con
flitti
, MD
S
ue B
ened
etti
Jum
an A
bjub
ara
Dan
Jan
sen
Cin
dy J
ohns
on
Nis
sa A
nder
son
Tad
Gar
y A
rlene
War
ren
Terr
i Wol
fang
K
ristin
e N
ewm
an
Bria
n H
orge
shim
er
Pat
ti S
imps
on
Inte
rim M
edia
l Dire
ctor
V
P, M
edic
al M
anag
emen
t V
P, Q
M &
Spe
cial
Pro
gram
s D
irect
or, P
reve
ntio
n &
Wel
lnes
s M
anag
er, C
ase
Man
agem
ent
EP
SD
T C
oord
inat
or
Beh
avio
ral H
ealth
Coo
rdin
ator
Q
M M
anag
er
Cre
dent
ialin
g O
pera
tions
Mgr
C
ompl
ianc
e M
anag
er
Com
plia
nce
Offi
cer
Com
plia
nce
Offi
cer,
Scha
ller
And
erso
n
DE
LIV
ER
Y S
YS
TEM
S A
ND
PR
OVI
DE
R R
ELA
TIO
NS
P
enny
Mar
shal
l C
athy
Wal
dbilli
g K
ristin
e N
ewm
an
Bria
n H
orge
shim
er
Dire
ctor
Net
wor
k D
evel
opm
ent &
C
ontra
ctin
g D
irect
or M
embe
r and
Enr
ollm
ent
Ser
vice
s C
ompl
ianc
e M
anag
er
Com
plia
nce
Offi
cer
FIN
AN
CIA
L M
AN
AG
EM
EN
T N
/A
CLA
IMS
AN
D IN
FOR
MA
TIO
N S
YS
TEM
S
N/A
E
NC
OU
NTE
RS
AN
D R
EIN
SU
RA
NC
E
N/A
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
9
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
10
CO
NTR
AC
TOR
STA
FF P
AR
TIC
IPA
TIO
N
NA
ME
TI
TLE
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
10
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
11
SCO
RIN
G M
ETH
OD
OLO
GY
The
Con
trac
tor w
as s
core
d in
eac
h ar
ea u
sing
the
follo
win
g ra
tings
: Fu
ll C
ompl
ianc
e Th
e C
ontra
ctor
is 9
0-10
0% in
com
plia
nce
with
the
stan
dard
requ
irem
ents
bas
ed o
n w
eigh
ted
findi
ngs.
S
ubst
antia
l C
ompl
ianc
e Th
e C
ontra
ctor
is 7
5-89
% in
com
plia
nce
with
the
stan
dard
requ
irem
ents
bas
ed o
n w
eigh
ted
findi
ngs.
Par
tial
Com
plia
nce
The
Con
tract
or is
50-
74%
in c
ompl
ianc
e w
ith th
e st
anda
rd re
quire
men
ts b
ased
on
wei
ghte
d fin
ding
s.
Non
-Com
plia
nce
The
Con
tract
or is
0-4
9% in
com
plia
nce
with
the
stan
dard
requ
irem
ents
bas
ed o
n w
eigh
ted
findi
ngs.
N
ot A
pplic
able
Th
e st
anda
rd d
oes
not a
pply
to th
e C
ontra
ctor
and
/or t
he s
tand
ard
is n
ot a
con
tract
ual r
equi
rem
ent
and/
or th
ere
have
bee
n no
inst
ance
s in
whi
ch th
e re
quire
men
t app
lied.
B
ased
on
the
findi
ngs
of th
e re
view
, one
of t
hree
Rec
omm
enda
tions
wer
e m
ade:
Th
e C
ontra
ctor
mus
t…
This
indi
cate
s cr
itica
l non
-com
plia
nce
in a
n ar
ea th
at m
ust b
e co
rrec
ted
as s
oon
as p
ossi
ble
to
be in
com
plia
nce
with
the
AH
CC
CS
con
tract
. Th
e C
ontra
ctor
sh
ould
…
This
indi
cate
s no
n-co
mpl
ianc
e in
an
area
that
mus
t be
corr
ecte
d to
be
in c
ompl
ianc
e w
ith th
e A
HC
CC
S c
ontra
ct, b
ut is
not
crit
ical
to th
e ev
eryd
ay o
pera
tion
of th
e C
ontra
ctor
. Th
e C
ontra
ctor
sho
uld
cons
ider
…
This
is a
sug
gest
ion
by th
e R
evie
w T
eam
to im
prov
e op
erat
ions
of t
he C
ontra
ctor
, alth
ough
it is
no
t dire
ctly
rela
ted
to c
ontra
ct c
ompl
ianc
e.
The
stan
dard
s us
ed b
y th
e re
view
ers
wer
e pr
ovid
ed to
the
Con
tract
or a
ppro
xim
atel
y tw
o w
eeks
prio
r to
the
onsi
te re
view
. Th
e R
evie
w T
eam
per
form
ed a
n ex
tens
ive
docu
men
t rev
iew
, con
duct
ed in
terv
iew
s w
ith a
ppro
pria
te C
ontra
ctor
per
sonn
el
and
obse
rved
the
staf
f whe
n ne
cess
ary.
Unl
ess
othe
rwis
e no
ted,
the
Con
tract
or h
ad th
e ap
prop
riate
writ
ten
polic
ies
for
each
of t
he a
reas
revi
ewed
.
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
11
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
12
QU
ALI
TATI
VE S
UM
MA
RY
OF
FIN
DIN
GS
A br
ief s
umm
ary
and
perfo
rman
ce a
sses
smen
t of e
ach
prog
ram
are
a fo
llow
s:
Mem
ber I
nfor
mat
ion
and
Adm
inis
trat
ive
Serv
ices
Th
e C
ontra
ctor
is in
full
com
plia
nce
with
all
acut
e ca
re s
tand
ards
. G
rieva
nces
are
trac
ked,
tren
ded,
and
ana
lyze
d.
Tele
phon
e pe
rform
ance
sta
ndar
ds a
re tr
acke
d.
Cas
e M
anag
emen
t O
vera
ll th
e C
ontra
ctor
has
ade
quat
e pr
oced
ures
in p
lace
for i
mpl
emen
ting
and
mon
itorin
g an
effe
ctiv
e ca
se m
anag
emen
t pr
ogra
m.
The
Con
tract
or w
ill ho
wev
er h
ave
to c
hang
e th
eir A
ssis
ted
Livi
ng F
acilit
y R
oom
and
Boa
rd p
roce
dure
to
addr
ess
requ
irem
ents
for m
inim
um R
&B
cha
rges
.
Med
ical
Man
agem
ent
The
Con
tract
or h
as in
clud
ed in
the
Med
ical
Man
agem
ent M
eetin
g m
inut
es a
s a
stan
ding
age
nda
item
UM
Dat
a an
alys
is;
how
ever
, the
re is
no
docu
men
tatio
n of
any
act
ions
or i
nter
vent
ions
impl
emen
ted
as a
resu
lt of
the
trend
s fo
und
durin
g th
e an
alys
is.
Aut
horiz
atio
n an
d G
rieva
nce
Syst
em
The
Con
tract
or h
as p
roce
sses
to ti
mel
y ac
know
ledg
e ap
peal
s an
d cl
aim
dis
pute
s. T
he a
ppea
l and
cla
im d
ispu
te p
roce
ss
cond
ucte
d by
the
Con
tract
or in
clud
es d
ocum
enta
tion
of th
e re
sear
ch a
nd m
edic
al re
view
s. O
vertu
rned
den
ials
hav
e do
cum
enta
tion
of a
utho
rizat
ion
upda
tes.
Th
e C
ontra
ctor
has
ach
ieve
d a
tota
l Not
ice
of A
ctio
n Le
tter a
udit
scor
e of
>90
% fo
r 3 c
onse
cutiv
e m
onth
s in
Acu
te C
are.
Th
e C
ontra
ctor
has
an
adeq
uate
pro
cess
in p
lace
for t
he is
suan
ce o
f a N
otic
e of
Ext
ensi
on le
tter b
ut th
e le
tter d
oes
not
incl
ude
the
date
the
requ
est w
ill ex
pire
in a
dditi
onal
info
rmat
ion
is n
ot re
ceiv
ed.
Mat
erna
l and
Chi
ld H
ealth
and
EPS
DT
The
Con
tract
or’s
effo
rts to
pro
vide
qua
lity
heal
th c
are
are
dem
onst
rate
d by
the
Con
tract
ors
activ
e pa
rtici
patio
n w
ith s
tate
ag
enci
es a
nd c
omm
unity
par
tner
s. T
he C
ontra
ctor
col
labo
rate
s w
ith A
rizon
a E
arly
Int
erve
ntio
n P
rogr
am (
AzE
IP)
to
educ
ate
AzE
IP p
rovi
ders
in a
ppro
pria
te r
egis
tratio
n, c
ontra
ctin
g an
d bi
lling
proc
esse
s as
wel
l as
wor
king
with
TA
PI
to
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
12
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
13
deve
lop
a pr
oces
s to
rei
mbu
rse
coun
ty h
ealth
dep
artm
ents
for
pro
vidi
ng s
ervi
ces
such
as
imm
uniz
atio
ns t
o M
edic
aid
mem
bers
. C
linic
al Q
ualit
y M
anag
emen
t Th
e C
ontra
ctor
has
an
effe
ctiv
e pr
oces
s fo
r ver
ifyin
g th
e cr
eden
tials
of c
ontra
cted
pro
vide
rs. T
he m
edic
al re
cord
revi
ew
proc
ess
is w
ell o
rgan
ized
via
pol
icy
and
proc
edur
e, im
plem
enta
tion
and
corre
ctiv
e ac
tion
plan
s w
hen
war
rant
ed.
Con
sist
ency
in d
ocum
entin
g th
e re
ferra
l of a
buse
, neg
lect
and
exp
loita
tion
case
s to
regu
lato
ry a
genc
ies
wou
ld s
treng
then
th
e co
ntra
ctor
’s q
ualit
y of
car
e pr
oces
s. T
he C
ontra
ctor
is p
erfo
rmin
g w
ell i
n A
HC
CC
S-m
anda
ted
Per
form
ance
Im
prov
emen
t Pro
ject
s an
d P
erfo
rman
ce M
easu
res;
how
ever
, it m
ust r
ever
se s
igni
fican
t dec
lines
in th
e A
cute
-car
e m
easu
res
of T
imel
ines
s of
Pre
nata
l Car
e an
d C
hlam
ydia
Scr
eeni
ng, a
nd im
prov
e al
l of i
ts A
cute
-car
e P
erfo
rman
ce
Mea
sure
rate
s to
mee
t AH
CC
CS
Min
imum
Per
form
ance
Sta
ndar
ds.
D
eliv
ery
Syst
ems
and
Prov
ider
Rel
atio
ns
The
Con
tract
or m
ust u
pdat
e its
pol
icie
s w
ith re
gard
to tr
acki
ng a
nd tr
endi
ng p
rovi
der i
nqui
ries,
in a
dditi
on to
resp
ondi
ng to
pr
ovid
er in
quiri
es w
ithin
the
cont
ract
ual r
equi
red
timef
ram
e. W
ritte
n no
tices
mus
t be
sent
in a
tim
ely
man
ner w
hen
the
Con
tract
or le
arns
of t
he re
sign
atio
n of
a p
rovi
der.
The
re is
an
adeq
uate
net
wor
k of
pra
ctiti
oner
s in
the
field
of e
ye c
are.
Fi
nanc
ial M
anag
emen
t Th
e C
ontra
ctor
is in
full
com
plia
nce
with
all
stan
dard
s. Q
uarte
rly, m
onth
ly, a
nd a
nnua
l fin
anci
al s
tate
men
ts a
re c
ompl
ete
and
timel
y. C
laim
s ar
e pa
id in
a ti
mel
y m
anne
r, an
d in
tere
st is
pai
d ap
prop
riate
ly.
C
laim
s an
d In
form
atio
n Sy
stem
s Th
e C
ontra
ctor
has
est
ablis
hed
proc
esse
s an
d pr
oced
ures
to m
onito
r the
acc
urac
y of
cla
ims
paym
ents
and
dat
a in
tegr
ity.
Sam
ple
size
s fo
r thi
s re
view
do
not r
epre
sent
sta
tistic
ally
sig
nific
ant a
ppra
isal
of c
erta
in a
reas
suc
h as
inte
grat
ion
of
AH
CC
CS
sup
plie
d in
form
atio
n; h
owev
er, t
he p
roce
sses
to id
entif
y an
d co
rrec
t err
ors
upon
iden
tific
atio
n ar
e ev
iden
t. En
coun
ters
and
Rei
nsur
ance
To
ens
ure
timel
y, a
ccur
ate,
and
com
plet
e su
bmis
sion
of e
ncou
nter
s, th
e C
ontra
ctor
has
app
ropr
iate
and
inte
grat
ed
syst
ems
in p
lace
to tr
ack
and
audi
t enc
ount
er d
ata.
Th
e C
ontra
ctor
sho
uld
upda
te a
ll re
insu
ranc
e de
skto
p pr
oced
ures
and
thei
r tra
nspl
ant m
anua
l to
refle
ct th
e cu
rren
t pr
oces
ses
requ
ired
by c
ontra
ct.
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
13
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
14
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
14
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
15
QU
AN
TITA
TIVE
SU
MM
AR
Y O
F FI
ND
ING
S
KEY
FC
FU
LL C
OM
PLI
AN
CE
S
C
SU
BS
TAN
TIA
L C
OM
PLI
AN
CE
P
C
PA
RTI
AL
CO
MP
LIA
NC
E
NC
N
ON
CO
MP
LIA
NC
E
NA
N
OT
AP
PLI
CA
BLE
IO
IN
FOR
MA
TIO
NA
L S
TAN
DA
RD
IN 2
009
SEC
TIO
N
STA
ND
AR
D
FIN
DIN
G
REC
OM
MEN
DA
TIO
N
Mem
ber I
nfor
mat
ion
and
Adm
inis
trat
ive
Serv
ices
MI 1
FC
N
one
M
I 2 (
Acu
te O
nly)
FC
N
one
M
I 3 (
Acu
te O
nly)
FC
N
one
M
I 4 (A
cute
Onl
y)
FC
Non
e M
edic
al M
anag
emen
t
MM
1
FC
Non
e
MM
2
NC
Th
e C
ontra
ctor
mus
t doc
umen
t any
act
ions
/inte
rven
tions
and
/or
any
chan
ges
mad
e as
a re
sult
of th
e ac
tions
or i
nter
vent
ions
bas
ed
on d
ata
revi
ewed
and
repo
rted
thro
ugh
the
Med
ical
Man
agem
ent
Com
mitt
ee.
M
M 3
FC
N
one
M
M 4
FC
Th
e C
ontra
ctor
sho
uld
cons
ider
incl
udin
g te
stin
g fo
r con
sist
ent
appl
icat
ion
of c
riter
ia w
hen
eval
uatin
g re
ques
ts fo
r tra
nspl
ant
serv
ices
in th
eir I
nter
-Rat
er R
elia
bilit
y te
stin
g.
M
M 5
FC
N
one
M
M 6
P
C
The
Con
tract
or m
ust
eval
uate
the
Pra
ctic
e G
uide
lines
ann
ually
th
roug
h a
mul
ti-di
scip
linar
y pr
oces
s to
det
erm
ine
if th
e gu
idel
ines
re
mai
n ap
plic
able
, an
d re
pres
ent
the
best
an
d m
ost
curr
ent
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
15
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
16
prac
tice
stan
dard
s.
M
M 7
FC
N
one
M
M 8
P
C
The
Con
tract
or m
ust r
epor
t the
inte
rven
tions
and
any
cha
nges
m
ade
to th
ose
inte
rven
tions
bas
ed o
n th
e ou
tcom
es o
r eva
luat
ion
of th
ose
inte
rven
tions
. Th
is m
ust b
e do
cum
ente
d in
the
mee
ting
min
utes
.
MM
9
FC
Non
e
MM
10
FC
Non
e
MM
11
(Acu
te O
nly)
S
C
The
Con
tract
or m
ust d
evel
op th
e m
etho
dolo
gy to
iden
tify
prov
ider
s w
illing
to p
rovi
de m
edic
al h
ome
serv
ices
and
mak
e re
ason
able
ef
forts
to o
ffer a
cces
s fo
r mem
bers
to th
ese
prov
ider
s.
Aut
horiz
atio
n an
d G
rieva
nce
Syst
em
G
S 1
A (A
cute
Onl
y)
SC
Th
e C
ontra
ctor
mus
t mak
e th
e st
anda
rdiz
ed a
utho
rizat
ion
crite
ria
avai
labl
e to
mem
bers
upo
n re
ques
t.
GS
2A
(Acu
te O
nly)
FC
N
one
G
S 3
A (A
cute
Onl
y)
FC
Non
e
GS
4A
(Acu
te O
nly)
S
C
The
Con
tract
or s
houl
d in
clud
e in
pol
icy
and
proc
edur
e th
at th
e re
ques
ting
prov
ider
is n
otifi
ed fo
r an
orde
r cha
nge
whe
n an
“e
xped
ited”
aut
horiz
atio
n re
ques
t doe
s no
t mee
t the
crit
eria
for
expe
dite
d au
thor
izat
ion
in o
rder
to d
eter
min
e w
hy th
e pr
ovid
er h
as
requ
este
d an
exp
edite
d re
view
.
GS
5A
(Acu
te O
nly)
S
C
The
Con
tract
or m
ust i
nclu
de in
thei
r Not
ice
of E
xten
sion
Let
ter a
st
atem
ent t
hat t
he d
ecis
ion
will
be m
ade
as e
xped
itiou
sly
as th
e m
embe
r’s c
ondi
tion
requ
ires
and
no la
ter t
han
the
date
that
the
exte
nsio
n is
set
to e
xpire
. The
Con
tract
or m
ust i
nclu
de in
thei
r N
otic
e of
Ext
ensi
on le
tter t
he d
ate
the
requ
est w
ill ex
pire
if th
e ad
ditio
nal i
nfor
mat
ion
is n
ot re
ceiv
ed.
G
S 6
FC
N
one
G
S 7
FC
N
one
G
S 8
FC
N
one
G
S 9
FC
N
one
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
16
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
17
G
S 1
0 FC
N
one
G
S 1
1 FC
N
one
G
S 1
2 FC
N
one
G
S 1
3 FC
N
one
G
S 1
4 FC
N
one
G
S 1
5 FC
N
one
G
S 1
6 FC
N
one
G
S 1
7 FC
N
one
G
S 1
8 FC
N
one
G
S 1
9 FC
N
one
G
S 2
0 FC
N
one
G
S 2
1 FC
N
one
G
S 2
2 FC
N
one
G
S 2
3 FC
N
one
G
S 2
4 FC
N
one
G
S 2
5 FC
N
one
G
S 2
6
FC
Non
e M
ater
nal a
nd C
hild
Hea
lth a
nd E
PSD
T
MC
H 1
FC
N
one
M
CH
2
FC
Non
e
MC
H 3
P
C
The
Con
tract
or m
ust e
nsur
e al
l prim
ary
care
pro
vide
rs d
eliv
erin
g ca
re to
EP
SD
T ag
ed m
embe
rs u
tiliz
e th
e ag
e ap
prop
riate
EP
SD
T Tr
acki
ng F
orm
s du
ring
each
EP
SD
T vi
sit a
nd im
plem
ent p
roce
sses
to
ens
ure
thos
e pr
ovid
ers
not u
sing
the
EP
SD
T Tr
acki
ng F
orm
s ar
e co
mpl
iant
with
usi
ng th
e fo
rms.
MC
H 4
FC
N
one
M
CH
5
FC
Non
e
MC
H 6
S
C
The
Con
tract
or s
houl
d ha
ve a
pro
cess
to c
oord
inat
e w
ith W
IC a
nd
the
mem
ber’s
gua
rdia
n w
hen
issu
es re
late
d to
WIC
ser
vice
s ar
e id
entif
ied.
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
17
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
18
M
CH
7 (A
cute
Onl
y)
FC
Non
e
MC
H 8
FC
N
one
M
CH
9
FC
Non
e
MC
H 1
0 (A
cute
Onl
y)
FC
Non
e
MC
H 1
1 (A
cute
Onl
y)
NA
N
one
M
CH
12
NA
N
one
Qua
lity
Man
agem
ent
Q
M 1
FC
N
one
Q
M 2
FC
N
one
Q
M 3
FC
N
one
Q
M 4
FC
N
one
Q
M 5
FC
N
one
Q
M 6
FC
N
one
Q
M 7
A (A
cute
Onl
y)
SC
Th
e C
ontra
ctor
mus
t mee
t the
AH
CC
CS
MP
S fo
r all
cont
ract
ual
perfo
rman
ce m
easu
res
and
impr
ove
its ra
tes
for t
hose
that
are
cu
rrent
ly b
elow
the
AH
CC
CS
MP
S.
MC
P h
as s
ubm
itted
CA
Ps
for
perfo
rman
ce m
easu
res
thro
ugh
the
Not
ice
to C
ure
proc
ess,
and
is
not r
equi
red
to s
ubm
it a
sepa
rate
CA
P fo
r thi
s st
anda
rd.
QM
8 A
(Acu
te O
nly)
FC
N
one
Q
M 9
FC
N
one
Q
M 1
0 FC
N
one
Q
M 1
1 FC
N
one
Q
M 1
2A (A
cute
Onl
y)
PC
Th
e C
ontra
ctor
mus
t ens
ure
cont
ract
ed P
CP
s up
date
the
mem
ber’s
beh
avio
ral h
ealth
pro
vide
r whe
n th
ere
are
chan
ges
in
the
mem
ber’s
dia
gnos
es o
r pre
scrib
ed m
edic
atio
n an
d ap
prop
riate
ly tr
ansi
tion
mem
bers
bei
ng tr
eate
d fo
r AD
HD
, de
pres
sion
and
anx
iety
to th
e R
BH
A to
mai
ntai
n co
ntin
uity
of c
are.
QM
13
FC
Non
e
QM
14A
(Acu
te O
nly)
S
C
The
Con
tract
or m
ust d
evel
op a
pro
cess
to e
nsur
e co
ntra
cted
PC
Ps
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
18
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
19
resp
ond
to re
ques
ts fo
r inf
orm
atio
n ab
out m
embe
rs re
ceiv
ing
beha
vior
al h
ealth
ser
vice
s fro
m b
ehav
iora
l hea
lth p
rovi
ders
is s
ent
by th
e P
CP
with
in 1
0 da
ys o
f rec
eivi
ng th
e re
ques
t. Th
e C
ontra
ctor
m
ust d
ocum
ent t
he s
tatu
s of
the
corre
ctio
n pl
an in
clud
ing
re-
eval
uatio
n to
con
firm
the
effe
ctiv
enes
s of
the
plan
.
QM
15
FC
Non
e
QM
16
FC
Non
e
QM
17
(Acu
te O
nly)
FC
N
one
Q
M 1
8 (A
cute
Onl
y)
FC
Non
e
QM
19
(Acu
te O
nly)
FC
N
one
Q
M 2
0 (A
cute
Onl
y)
FC
Non
e
QM
21
(Acu
te O
nly)
N
A
Non
e
QM
22
(Acu
te O
nly)
FC
N
one
Q
M 2
3 (A
cute
Onl
y)
FC
Non
e
QM
24
(Acu
te O
nly)
N
C
The
Con
tract
or m
ust h
ave
a m
echa
nism
in p
lace
to id
entif
y m
embe
rs w
ho h
ave
com
plet
ed s
tep
ther
apy
and
are
retu
rnin
g to
th
e ca
re o
f the
ir P
CP
s fo
r the
trea
tmen
t of d
epre
ssio
n, a
nxie
ty, o
r A
DH
D.
The
Con
tract
or m
ust m
onito
r its
PC
Ps
to e
nsur
e th
at th
ey p
resc
ribe
med
icat
ions
in c
onsi
sten
ce w
ith th
ose
pres
crib
ed b
y th
e R
BH
A
prov
ider
s w
hen
a m
embe
r has
com
plet
ed s
tep
ther
apy.
Th
e C
ontra
ctor
mus
t req
uire
PC
Ps
to c
onsu
lt w
ith, o
r obt
ain
info
rmat
ion
from
the
RBH
A p
rovi
ders
for m
embe
rs w
ho re
port
havi
ng tr
ied
seve
ral m
edic
atio
ns/h
ave
parti
cipa
ted
in s
tep
ther
apy
for t
he tr
eatm
ent o
f dep
ress
ion,
anx
iety
, or A
DH
D p
rior t
o th
eir
curr
ent m
edic
atio
n re
gim
e.
The
Con
tract
or m
ust a
utho
rize
med
icat
ions
orig
inal
ly p
resc
ribed
by
a R
BH
A p
rovi
der f
or m
embe
rs w
ho h
ave
com
plet
ed s
tep
ther
apy.
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
19
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
20
Q
M 2
5 FC
Non
e D
eliv
ery
Syst
ems
and
Prov
ider
Rel
atio
ns
D
S 1
S
C
The
Con
tract
or m
ust u
pdat
e its
pol
icy
to re
flect
the
corre
ct
timef
ram
e fo
r res
olvi
ng p
rovi
der i
nqui
ries.
In
addi
tion,
the
Con
tract
or m
ust r
esol
ve a
ll in
quiri
es w
ithin
the
requ
ired
timef
ram
e of
30
busi
ness
day
s.
D
S 2
(Acu
te O
nly)
N
C
The
Con
tract
or m
ust u
pdat
e its
pol
icie
s an
d de
skto
p pr
oced
ures
to
incl
ude
spec
ific
info
rmat
ion
on p
rovi
ding
tran
spor
tatio
n fo
r m
embe
rs w
ith o
ngoi
ng tr
eatm
ent n
eeds
. Th
e re
fere
nce
to
“bla
nket
” tra
nspo
rtatio
n in
the
polic
y is
not
suf
ficie
nt.
D
S 3
(Acu
te O
nly)
FC
N
one
D
S 4
(Acu
te O
nly)
P
C
The
Con
tract
or m
ust t
ake
corre
ctiv
e ac
tion
whe
n ne
cess
ary
base
d on
the
surv
ey re
port
resu
lts.
Cla
ims
and
Info
rmat
ion
Syst
ems
C
IS 1
FC
N
one
C
IS 2
(Acu
te O
nly)
FC
N
one
C
IS 3
(Acu
te O
nly)
FC
N
one
C
IS 4
(Acu
te O
nly)
S
C
The
Con
tract
or s
houl
d co
ntin
ue e
fforts
to p
rom
ote
elec
troni
c pa
ymen
t to
elec
troni
c su
bmitt
ers
as th
ey a
re m
ost l
ikel
y to
ado
pt.
C
IS 5
(Acu
te O
nly)
FC
N
one
C
IS 6
FC
Th
e C
ontra
ctor
sho
uld
clar
ify in
pol
icy
wha
t per
iodi
city
will
be fo
r ea
ch li
ne o
f bus
ines
s.
C
IS 7
S
C
The
Con
tract
or s
houl
d de
velo
p pr
oces
ses
for t
he v
alid
atio
n of
in
tegr
ated
mem
ber f
iles
agai
nst A
HC
CC
S s
uppl
ied
data
.
CIS
8 (A
cute
Onl
y)
FC
Non
e En
coun
ters
and
Rei
nsur
ance
ENC
1
FC
Non
e
ENC
2
FC
Non
e
ENC
3
FC
Non
e
ENC
4
FC
Non
e
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
20
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ERC
Y C
AR
E PL
AN
EX
ECU
TIVE
SU
MM
AR
Y
21
EN
C 5
FC
N
one
EN
C 6
FC
N
one
EN
C 7
FC
N
one
EN
C 8
FC
N
one
E
NC
9 A
(Acu
te O
nly)
FC
N
one
EN
C 1
0 FC
N
one
EN
C 1
1 FC
N
one
E
NC
12
(Acu
te O
nly)
FC
N
one
R
I 1
FC
The
Con
tract
or s
houl
d co
nsid
er a
pply
ing
the
trans
plan
t sta
ge
bala
ncin
g pr
oces
ses
as d
etai
led
in th
eir p
roce
dure
s.
R
I 2
SC
Th
e C
ontra
ctor
sho
uld
ensu
re th
e co
ordi
natio
n be
twee
n th
eir
med
ical
man
agem
ent,
enco
unte
rs, a
nd re
insu
ranc
e fin
ance
un
its to
pro
duce
an
acce
ptab
le o
utco
me
for t
he c
ontra
ct
requ
irem
ent o
f tra
nspl
ant s
ervi
ces
as it
per
tain
s to
CN
1/su
bcap
co
de.
R
I 3
NC
Th
e C
ontra
ctor
sho
uld
upda
te th
eir d
eskt
op p
roce
dure
s to
incl
ude
the
spec
ific
cont
ract
lang
uage
for n
otifi
catio
n of
any
type
of
rein
sura
nce
over
paym
ents
with
in th
e co
ntra
cted
tim
e fra
me.
The
C
ontra
ctor
sho
uld
appl
y a
repo
rt fo
r mon
itorin
g th
e ap
prop
riate
ness
of
the
rein
sura
nce
reve
nue
rece
ived
aga
inst
pai
d cl
aim
s da
ta.
R
I 4
NA
N
one
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
21
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ercy
Car
e Pl
an
Mem
ber I
nfor
mat
ion
and
Adm
inis
trat
ive
Serv
ices
24
Stan
dard
MI 1
Mem
ber N
ewsl
ette
rs c
onta
in th
e in
form
atio
n re
quire
d by
Con
trac
t. [C
ontr
act S
ectio
n D
, Par
agra
ph 1
8;
42C
FR43
8.10
] Fi
ndin
gs:
FU
LL C
OM
PLIA
NC
E
The
Con
tract
or h
as p
rodu
ced
and
dist
ribut
ed th
e ap
prop
riate
num
ber o
f new
slet
ters
(as
dete
rmin
ed b
y th
e tim
ing
of th
e re
view
).
The
new
slet
ters
con
tain
info
rmat
ion
on/fo
r:
√ C
hron
ic il
lnes
s se
lf-m
anag
emen
t. (1
0%)
√ P
reve
ntiv
e m
easu
res
such
as
flu-s
hots
. (10
%)
C
ultu
ral C
ompe
tenc
y ot
her t
han
trans
latio
n in
form
atio
n. (1
0%)
√ To
bacc
o ce
ssat
ion.
(10%
)
HIV
/AID
S te
stin
g fo
r pre
gnan
t mem
bers
. (10
%)
M
edic
are
Par
t D m
embe
rs. (
10%
) D
ocum
ents
Rev
iew
ed
Fa
ll 20
08 M
embe
r New
slet
ter
Win
ter 2
009
Mem
ber N
ewsl
ette
r M
embe
r New
slet
ter T
opic
s fo
r 200
9 C
omm
ents
The
Con
tract
or s
ubm
itted
Mem
ber N
ewsl
ette
r Top
ics
for t
he S
prin
g an
d S
umm
er 2
009
new
slet
ters
. Th
ese
new
slet
ters
w
ill co
ntai
n in
form
atio
n on
HIV
/AID
S te
stin
g fo
r pre
gnan
t mem
bers
, cul
tura
l com
pete
ncy
othe
r tha
n tra
nsla
tion
info
rmat
ion
and
info
rmat
ion
for M
edic
are
Par
t D m
embe
rs.
Rec
omm
enda
tions
Non
e
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
22
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ercy
Car
e Pl
an
Mem
ber I
nfor
mat
ion
and
Adm
inis
trat
ive
Serv
ices
25
Stan
dard
MI 2
(A
cute
Onl
y)
M
embe
r Ser
vice
s, T
rans
port
atio
n, a
nd P
rior A
utho
rizat
ion
staf
f hav
e ac
cess
to, a
nd u
tiliz
e, a
ppro
pria
te m
appi
ng
serv
ices
whe
n as
sign
ing
PCPs
; sch
edul
ing
appo
intm
ents
; and
refe
rrin
g m
embe
rs to
ser
vice
s an
d/or
ser
vice
pr
ovid
ers.
[Con
trac
t Sec
tion
D, P
arag
raph
16]
Fi
ndin
gs:
FU
LL C
OM
PLIA
NC
E
The
Con
tract
or d
oes
mai
ntai
n po
licie
s an
d pr
oced
ures
on
the
use
of m
appi
ng s
ervi
ces
to d
eter
min
e ap
prop
riate
ser
vice
lo
catio
ns. (
34%
) D
esk
Ref
eren
ce a
nd/o
r tra
inin
g m
ater
ials
con
tain
info
rmat
ion
on m
appi
ng s
ervi
ces.
(33%
) R
evie
wer
was
abl
e to
obs
erve
or c
onfir
m th
roug
h in
depe
nden
t int
ervi
ew th
at m
appi
ng s
ervi
ces
are
acce
ssib
le a
nd u
tiliz
ed
by s
taff
in th
e th
ree
depa
rtmen
ts m
entio
ned
in th
e st
anda
rd. (
33%
) D
ocum
ents
Rev
iew
ed
M
embe
r Ser
vice
s M
anua
l-Cha
pter
15-
Tran
spor
tatio
n Tr
aini
ng S
hare
Poi
nt M
ater
ial
Pol
icy
– 45
00.0
2 –M
embe
r/Pro
vide
r Ass
ocia
tion
Pol
icy
MS
601
– T
rans
porta
tion
Mem
ber S
ervi
ces
Rep
rese
ntat
ive
Inte
rvie
w
Com
men
ts
N
one
Rec
omm
enda
tions
Non
e
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
23
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ercy
Car
e Pl
an
Mem
ber I
nfor
mat
ion
and
Adm
inis
trat
ive
Serv
ices
26
Stan
dard
MI 3
(A
cute
Onl
y)
Th
e C
ontr
acto
r has
acc
urat
e m
echa
nism
s in
pla
ce to
trac
k te
leph
one
perf
orm
ance
mea
sure
s as
def
ined
in
para
grap
h 25
of t
he c
ontr
act.
[Con
trac
t Sec
tion
D, P
arag
raph
25]
Fi
ndin
gs:
FU
LL C
OM
PLIA
NC
E
The
Con
tract
or m
aint
ains
pol
icie
s an
d pr
oced
ures
on
track
ing
tele
phon
e pe
rform
ance
mea
sure
s. (5
0%)
The
Con
tract
or c
an p
rodu
ce th
e da
ta u
pon
requ
est.
(50%
) D
ocum
ents
Rev
iew
ed
D
eskt
op P
roce
dure
: A
dmin
istra
tive
Per
form
ance
Sta
ndar
ds R
epor
ting
Ava
ya C
all M
anag
emen
t Sys
tem
Rep
ort
Com
men
ts
N
one
Rec
omm
enda
tions
Non
e
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
24
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ercy
Car
e Pl
an
Mem
ber I
nfor
mat
ion
and
Adm
inis
trat
ive
Serv
ices
27
Stan
dard
MI 4
(A
cute
Onl
y)
Th
e C
ontr
acto
r ana
lyze
s an
d tr
ends
and
act
s up
on m
embe
r inq
uiry
and
grie
vanc
e da
ta. [
Con
trac
tor S
ectio
n D
, Pa
ragr
aph
26; A
CO
M P
olic
y 40
6]
Find
ings
: F
ULL
CO
MPL
IAN
CE
Th
e C
ontra
ctor
has
evi
denc
e of
ana
lyzi
ng a
nd tr
endi
ng m
embe
r inq
uirie
s an
d gr
ieva
nces
. (75
%)
The
Con
tract
or h
as e
vide
nce
of im
plem
entin
g co
rrect
ive
actio
n ba
sed
on m
embe
r inq
uiry
and
grie
vanc
e da
ta w
hen
appr
opria
te. (
25%
) D
ocum
ents
Rev
iew
ed
M
onth
ly K
ey S
ervi
ce In
dica
tor R
epor
t A
cute
Mem
ber G
rieva
nce
& P
CP
Cha
nge
Sum
mar
y R
epor
t – 1
st Q
tr. 2
009
Acu
te M
embe
r Grie
vanc
e &
PC
P C
hang
e S
umm
ary
Rep
ort –
Ann
ual 2
008
Mem
ber S
ervi
ces
Sum
mar
y 20
08
Qua
lity
Man
agem
ent O
vers
ight
Mee
ting
Min
utes
– F
ebru
ary
2009
C
omm
ents
Non
e R
ecom
men
datio
ns
N
one
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
25
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ercy
Car
e Pl
an
MED
ICA
L M
AN
AG
EMEN
T
45
Stan
dard
MM
1
Th
e C
ontr
acto
r has
impl
emen
ted
proc
edur
es fo
r util
izat
ion
man
agem
ent p
rogr
am re
quire
men
ts, w
hich
are
co
nsis
tent
with
AH
CC
CS
stan
dard
s, p
rovi
der m
onito
ring
and
an e
valu
atio
n of
ser
vice
s. [A
MPM
Cha
pter
100
0;
42C
FR43
8.24
0]
Find
ings
: FU
LL C
OM
PLIA
NC
E
The
Con
tract
or h
as im
plem
ente
d pr
oces
ses
for m
onito
ring
and
eval
uatin
g ut
ilizat
ion
of s
ervi
ces
for w
hich
the
plan
has
id
entif
ied
varia
nces
(bot
h un
der-
and
over
-util
izat
ion)
in u
tiliz
atio
n pa
ttern
s.
The
Con
tract
or d
oes
asse
ss th
e qu
ality
of s
ervi
ces
prov
ided
whe
n ut
ilizat
ion
data
var
ianc
es a
re p
rese
nt (u
nder
- and
ove
r-ut
iliza
tion)
. Th
e C
ontra
ctor
doe
s ha
ve a
crit
erio
n th
at o
utlin
es th
e va
rianc
e cr
iteria
that
wou
ld id
entif
y m
embe
rs a
nd p
rovi
ders
who
re
quire
inte
rven
tion
in o
rder
to c
orre
ct m
is-u
tiliz
atio
n pa
ttern
s.
The
Con
tract
or d
oes
act o
n id
entif
ied
varia
nces
(hig
h or
low
util
izat
ion)
. D
ocum
ents
Rev
iew
ed
U
M E
valu
atio
n C
Y08
; pa
ges
12-1
4 an
d pa
ges
35-3
7 P
harm
acy
Util
izat
ion
Man
agem
ent P
olic
y #7
600.
15
QM
-UM
Mee
ting
Min
utes
- Jan
uary
200
8 th
roug
h D
ecem
ber 2
008
Pha
rmac
y R
epor
ts
Mon
thly
UM
and
QM
dat
a re
ports
O
ver/U
nder
Util
izat
ion
Pol
icy
7000
.35
Com
men
ts
Non
e
R
ecom
men
datio
ns
N
one
Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic
Service Areas A, B and C Section B.24 - Requirement § 2,3 and 4
26
-
AH
CC
CS
OFR
Sta
ndar
ds
CYE
200
9 M
ercy
Car
e Pl
an
MED
ICA
L M
AN
AG
EMEN
T
46
Stan
dard
MM
2
Th
e C
ontr
acto
r rev
iew
s ut
iliza
tion
data
; rep
orts
tren
ds a
nd v
aria
nces
; im
plem
ents
, ana
lyze
s an
d ev
alua
tes
inte
rven
tions
and
act
s on
the
reco
mm
enda
tions
of t
he M
edic
al M
anag
emen
t Com
mitt
ee. [
AM
PM C
hapt
er 1
000;
42
CFR
438.
240]
Fi
ndin
gs:
NO
N C
OM
PLIA
NC
E
The
Con
tract
or d
oes
not h
ave
Med
ical
Man
agem
ent
