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  • Multi-Specialty FQHC RHC HCA & HCG Revised April 2015 (1) Page 1 of 29 County of Yavapai dba Yavapai County Community Health Services

    HEALTH CHOICE ARIZONA FEE-FOR-SERVICE PRIMARY/SPECIALTY PHYSICIAN, DENTIST

    SUBCONTRACTOR AGREEMENT

    This Agreement is entered into between HEALTH CHOICE ARIZONA, Inc, a Delaware Corporation (hereinafter referred to as HCA or CONTRACTOR), and County of Yavapai dba Yavapai County Community Health Services (hereinafter referred to as SUBCONTRACTOR), who will provide services to HCA MEMBERS.

    County of Yavapai dba Yavapai County Community Health Services Participating Health Professional

    1090 Commerce Drive

    Business Street Address Prescott, Arizona 86305-3700

    City, State, Zip Code

    RECITALS WHEREAS, HCA has entered into a contract with Arizona Health Care Cost Containment System (AHCCCS), A.R.S. 36-2901, et. seq. to provide and/or arrange for the provision of COVERED SERVICES to MEMBERS. WHEREAS, HCA dba Health Choice Generations (HC Generations) has entered into a contract with Centers for Medicare and Medicaid Services (CMS) to provide and/or arrange for or administer the provisions of health care services to Medicare beneficiaries; and WHEREAS, SUBCONTRACTOR is a physician, hospital, pharmacy, skilled nursing facility or other health care provider properly licensed, certified and/or accredited, as applicable, within the State of Arizona, that desires to enter into this Agreement to provide COVERED SERVICES to MEMBERS. WHEREAS, the Parties desire to enter into this Agreement in order to facilitate the provision of cost effective, covered health care services to MEMBERS. NOW THEREFORE, HCA and SUBCONTRACTOR agree to abide by all terms and conditions set forth in this Agreement, including Attachments, if any, to this Agreement. IN WITNESS WHEREOF, this Agreement having been duly executed by the authorized representatives of HCA and SUBCONTRACTOR will become effective the first of the month following the execution of the agreement by both parties.

    Agreement effective date is: ___________

    FOR AND ON BEHALF OF HCA FOR AND ON BEHALF OF SUBCONTRACTOR

    Signature Signature

    Typed Name Typed Name

    Title Title 86-6000561 Date Subcontractor Federal Tax Number

    AHCCCS Identification Number / Group NPI

    Date

    c08366Typewritten TextSee attached roster

  • Multi-Specialty FQHC RHC HCA & HCG Revised April 2015 (1) Page 2 of 29 County of Yavapai dba Yavapai County Community Health Services

    SECTION 1 - DEFINITIONS 1.1 638 TRIBAL FACILITY A facility that is operated by an Indian tribe and that is authorized to

    provide services pursuant to Public Law (PL.) 93-638, as amended. 1.2 1931 (also referred to as TANF related) - Eligible individuals and families under Section

    1931 of the Social Security Act, with household income levels at or below 100% of the federal poverty level (FPL).

    1.3 ABUSE (of MEMBER) - Intentional affliction of physical harm injury caused by negligent acts or omissions, unreasonable, confinement, sexual or emotional abuse or sexual assault. [A.R.S. Section 46-451 and 13-3623]

    1.4 ABUSE (BY SUBCONTRACTOR) - Provider practices that are inconsistent with sound fiscal, business or medical practice and result in an unnecessary cost to the AHCCCS program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the AHCCCS program. [42 CFR 455.2]

    1.5 ACOM - AHCCCS Contractor Operations Manual, available on the AHCCCS website at www.azahcccs.gov.

    1.6 ADHS - Arizona Department of Health Services, the state agency mandated to serve the

    public health needs of all Arizona residents. 1.7 ADHS BEHAVIORAL HEALTH RECIPIENT - A Title XIX or Title XXI acute care member who

    is -receiving behavioral health services through ADHS and its subcontractors. 1.8 ADJUDICATED CLAIMS - Claims that have been received and processed by the Contractor

    which resulted in a payment or denial of payment.

    1.9 ADVERSE ACTION - Any action for which a Provider may file a Claim Dispute. 1.10 ANCILLARY CARE - All COVERED SERVICES other than physician and hospital inpatient

    services which are ordered or approved by a physician, including but not limited to, radiology, laboratory, ambulance transportation, home health, skilled nursing and pharmacy services.

    1.11 AGENT - Any person who has been delegated the authority to obligate or act on behalf of another person or entity.

    1.12 AHCCCS - Arizona Health Care Cost Containment System, which is composed of the

    Administration, Contractors, and other arrangements through which health care services are provided to an eligible person, as defined by A.R.S. 36-2902, et seq.

    1.13 AHCCCS BENEFITS - See "COVERED SERVICES". 1.14 AHCCCS CARE - Eligible individuals and childless adults whose income is less than or equal

    to 100% of the FPL, and who are not categorically linked to another Title XIX program. (Formerly Non-MED)

    1.15 AHCCCS MEMBER - See "MEMBER".

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  • Multi-Specialty FQHC RHC HCA & HCG Revised April 2015 (1) Page 3 of 29 County of Yavapai dba Yavapai County Community Health Services

    1.16 ALTCS - The Arizona Long Term Care System, a program under AHCCCS that delivers long-term, acute, behavioral health and case management services to eligible members, as authorized by A.R.S. 36-2932.

    1.17 AMBULATORY CARE - Preventive, diagnostic and treatment services provided on an

    outpatient basis by physicians, nurse practitioners, physician assistants and other health care providers.

    1.18 AMERICAN INDIAN HEALTH PROGRAM (AIHP) - AIHP is an acute care FFS program

    administered by AHCCCS for eligible American Indians which reimburses for services provided by and through the Indian Health Service (IHS), tribal health programs operated under PL 93-638 or any other AHCCCS registered provider. AIHP was formerly known as AHCCCS IHS.

    1.19 AMPM - AHCCCS Medical Policy Manual, available on the AHCCCS website at www.azahcccs.gov.

    1.20 ANNUAL ENROLLMENT CHOICE (AEC) - The opportunity for a person to change

    contractors every 12 months, effective on their anniversary date. 1.21 ANNIVERSARY DATE - The anniversary date is 12 months from the date enrolled with the

    Contractor and annually thereafter. In some cases, the anniversary date will change based on the last date the member changed Contractors or the last date the member was given an opportunity to change,

    1.22 APPEAL RESOLUTION - The written determination by the Contractor concerning an appeal. 1.23 ARIZONA ADMINISTRATIVE CODE (A.A.C.) - Arizona Administrative Code. State

    regulations established pursuant to relevant statutes. Referred to in Contract as "AHCCCS Rules".

    1.24 AT RISK - Refers to the period of time that a member is enrolled with a Contractor during

    which time the Contractor is responsible to provide AHCCCS covered services under capitation.

    1.25 A.R.S. - Arizona Revised Statutes. 1.26 BBA - The Balanced Budget Act of 1997. 1.27 BIDDER'S LIBRARY A repository of manuals, statutes, rules and other reference material

    located on the AHCCCS website at www.azahcccs.gov. 1.28 BOARD CERTIFIED - An individual who has successfully completed all prerequisites of the

    respective specialty board and successfully passed the required examination for certification. 1.29 BORDER COMMUNITIES - Cities, towns or municipalities located in Arizona and within a

    designated geographic service area whose residents typically receive primary or emergency care in adjacent Geographic Service Areas (GSA) or neighboring states, excluding neighboring countries, due to service availability or distance. (R9-22-201.F, R9-22-201.G, R9-22-101.B)

    1.30 BREAST AND CERVICAL CANCER TREATMENT PROGRAM (BCCTP) - Eligible

    individuals under the Title XIX expansion program for women with income up to 250% of the

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  • Multi-Specialty FQHC RHC HCA & HCG Revised April 2015 (1) Page 4 of 29 County of Yavapai dba Yavapai County Community Health Services

    FPL, who are diagnosed with and need treatment for breast and/or cervical cancer or cervical lesions and are not eligible for other Title XIX programs providing full Title XIX services. Qualifying individuals cannot have other creditable health insurance coverage, including Medicare.

    1.31 CAPITATION - Payment to a Contractor by AHCCCS of a fixed monthly payment per person

    in advance, for which the Contractor provides a full range of covered services as authorized under A.R.S. 36-2904 and 36-2907.

    1.32 CATEGORICALLY LINKED TITLE XIX MEMBER - Member eligible for Medicaid under Title

    XIX of the Social Security Act including those eligible under 1931 provisions of the Social Security Act, Sixth Omnibus Budget Reconciliation Act (SOBRA), Supplemental Security Income (SSI), and SSI-related groups. To be categorically linked, the member must be aged 65 or over, blind, disabled, a child under age 19, a parent of a dependent child, or pregnant.

    1.33 CLAIM DISPUTE - A dispute, filed by a provider or Contractor, whichever is applicable,

    involving a payment of a claim, denial of a claim, imposition of a sanction or reinsurance. 1.34 CLEAN CLAIM - A claim that may be processed without obtaining additional information from

    the provider of service or from a thi