Common use of County Obligations Clause in Contracts

County Obligations. 27 A. COUNTY shall provide oversight of the MSI Program, including appropriate program 28 administration, coordination, planning, evaluation, financial and contract monitoring, public information 29 and referral, standards assurance, and review and analysis of data gathered and reported. 30 B. COUNTY shall establish either directly and/or through subcontract(s), a Utilization 31 Management Department (UMD) which shall: 32 1. Coordinate and make arrangements for the medical needs and care of MSI Eligibles. The 33 UMD shall not be responsible for the coordination of social services needs of such patients. 34 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 level of care, and utilization of all services provided to MSI Patients by All Providers. The parties 36 understand that the UMD shall use the latest available version of the Milliman Continuum of Care 37 Criteria as its guideline for such utilization review. COUNTY acknowledges that HOSPITAL may use 1 Interqual criteria for similar purposes within its own operations and with this understanding: 2 // 3 // 4 a. Prior to recommendation of denial of any inpatient day provided by HOSPITAL that 5 does not meet Milliman criteria, the UMD shall notify HOSPITAL of a pending denial recommendation 6 within two (2) business days of such determination. 7 b. HOSPITAL shall have the opportunity to provide written justification, within two (2) 8 business days after receiving written notice of recommended denial, to the UMD which justification 9 may include the application of Interqual criteria and/or other supporting information, as HOSPITAL 10 deems necessary. 11 c. If the UMD subsequently recommends denial of the inpatient day, HOSPITAL shall 12 have the right to appeal the decision to the Medical Review Committee as specified in Paragraph V. of 13 this Exhibit A to the Agreement. 14 3. Communicate with HOSPITAL regarding diversions, admissions, and discharge planning. 15 4. Assist in coordinating the transitions of MSI Patients to appropriate outpatient care, lower 16 levels of care or needed services through COUNTY contracted providers for skilled nursing facilities, 17 durable medical equipment and pharmacy services and through community-based providers for home 18 health care. 19 5. Conduct patient, HOSPITAL, and Other Provider education which shall include, but not be 20 limited to: 21 a. Availability of MSI Program services at locations other than UCI Medical Center. 22 b. MSI Program services available at Community Clinics 23 c. Services for which pre-authorization is recommended through the UMD. 24 C. Upon mutual written agreement, COUNTY may enter into separate agreements for Sub-Acute 25 Services for MSI Eligibles or MSI Patients. Execution of such agreements shall be contingent upon 26 mutual written agreement regarding the definition of sub-acute services, implementation, and payment 27 procedures. 28 D. ADMINISTRATOR may negotiate additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by the MSI Program Medical Director, 30 and authorized in writing by ADMINISTRATOR, at a number of Points negotiated by

County Obligations. 27 2 A. COUNTY ADMINISTRATOR shall provide oversight of the MSI MSN Program, including appropriate 3 program 28 administration, coordination, planning, evaluation, financial and contract monitoring, public 4 information 29 and referral, standards assurance, and review and analysis of data gathered and reported. 5 Any administrative duty or obligation to be performed pursuant to thethis Agreement on a weekend or 6 holiday may be performed on the next regular business day. 30 7 B. COUNTY ADMINISTRATOR shall establish establish, either directly and/or through subcontract(s), a Utilization 31 Management Department Care 8 Coordination Unit (UMDCCU) which shall: 32 9 1. Coordinate and make arrangements for the medical needs and care of MSI EligiblesMSN Enrollees. The 33 UMD 10 CCU shall not be responsible for the coordination of the social services needs of such patients. 34 11 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 12 level of care, and utilization of all services provided to MSI MSN Patients by All Providers. The parties 36 13 understand that the UMD CCU shall use the latest available version of the Milliman Continuum of Care 37 Criteria 14 Criteria, or other appropriate criteria as approved by ADMINISTRATOR, as its guideline for such 15 utilization review. COUNTY ADMINISTRATOR acknowledges that HOSPITAL CONTRACTOR may use 1 Interqual criteria 16 for similar purposes within its own operations and with this understanding: 2 // 3 //: 4 17 a. Prior to recommendation of any adjustment in the level of care or denial of any 18 inpatient day provided by HOSPITAL CONTRACTOR that 5 does not meet Milliman criteriacontinuum of care criteria used by the 19 CCU, the UMD CCU shall notify HOSPITAL CONTRACTOR of a pending denial recommendation 6 within two (2) business days 20 of such determination. 7 21 b. HOSPITAL CONTRACTOR shall have the opportunity to provide written justification, within two 22 (2) 8 business days after receiving written notice of recommended denialrecommendation, to the UMD CCU which justification 9 may 23 include the application of Interqual criteria and/or other supporting information, as HOSPITAL 10 CONTRACTOR 24 deems necessary. 11 25 c. If the UMD CCU subsequently recommends the adjustment and/or denial of the inpatient day, HOSPITAL 26 CONTRACTOR shall 12 have the right to appeal the decision to the Medical Review Policy Committee, as 27 established by ADMINISTRATOR. 28 d. Intermediary shall reimburse hospital based on the determination of the CCU or 29 Medical Policy Committee as specified in Paragraph V. of 13 this Exhibit A to the Agreementappropriate. 14 30 3. Communicate with HOSPITAL CONTRACTOR regarding diversions, patient transfers, admissions, and 31 discharge planning. 15 32 4. Assist in coordinating the transitions of MSI MSN Patients to appropriate outpatient care, lower 16 33 levels of care or other needed services through COUNTY contracted providers for skilled nursing 34 facilities, 17 durable medical equipment and equipment, pharmacy services and through community-based providers for home 18 health care. 19 5. Conduct patient35 C. When needed services are not available through any Contracting Hospital, HOSPITALADMINISTRATOR 36 may negotiate separate Letters of Agreement with rates appropriate for securing care for the provision of 37 // 1 such services with other Contracting Hospitals, and Other Provider education which shall includeor Non-Contract Hospitals, but including those that may not 2 be 20 limited to: 21 a. Availability of MSI Program services at locations other than UCI Medical Centerlocated in Orange County. 22 b. MSI Program services available at Community Clinics 23 c. Services for which pre-authorization 3 D. If an MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every 4 reasonable best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility 5 that is recommended through the UMDoperated by or has contracted with COUNTY to provide such acute psychiatric treatment. 24 C. Upon mutual written agreement6 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY may enter into separate agreements for Sub-Acute 25 7 shall neither have, nor exercise, any control or direction over the methods by which CONTRACTOR 8 shall perform its obligations under thethis Agreement. The standards of medical care and professional 9 duties of CONTRACTOR’s employees providing Hospital Services for MSI Eligibles or MSI Patients. Execution of such agreements under thethis Agreement shall be contingent upon 26 mutual written agreement regarding 10 determined, as applicable, by CONTRACTOR’s Board of Directors and the definition standards of sub-acute services, implementation, care in the 11 community in which CONTRACTOR is located and payment 27 procedures. 28 D. all applicable provisions of law and other rules and 12 regulations of any and all governmental authorities relating to licensure and regulation of COUNTY Obligations Paragraph of this Exhibit A to the Agreement. F. CONTRACTOR and ADMINISTRATOR may negotiate additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by mutually agree, in writing, to modify the MSI Program Medical Director, 30 and authorized in writing by ADMINISTRATOR, at a number of Points negotiated by13 CONTRACTOR. 14

County Obligations. 27 28 A. COUNTY ADMINISTRATOR shall provide oversight of the MSI MSN Program, including appropriate program 28 29 administration, coordination, planning, evaluation, financial and contract monitoring, public information 29 30 and referral, standards assurance, and review and analysis of data gathered and reported. Any 31 administrative duty or obligation to be performed pursuant to the Contract on a weekend or holiday may 32 be performed on the next regular business day. 30 33 B. COUNTY ADMINISTRATOR shall establish establish, either directly and/or through subcontract(s), a Utilization 31 Management Department Care 34 Coordination Unit (UMDCCU) which shall: 32 35 1. Coordinate and make arrangements for the medical needs and care of MSI EligiblesMSN Enrollees. The 33 UMD 36 CCU shall not be responsible for the coordination of the social services needs of such patients.. 37 // 34 1 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 level 2 of care, and utilization of all services provided to MSI MSN Patients by All Providers. The parties 36 understand 3 that the UMD CCU shall use the latest available version of the Milliman Continuum of Of Care 37 Criteria Criteria, or other 4 appropriate criteria as approved by ADMINISTRATOR, as its guideline for such utilization review. COUNTY 5 ADMINISTRATOR acknowledges that HOSPITAL CONTRACTOR may use 1 Interqual criteria for similar purposes 6 within its own operations and with this understanding: 2 // 3 //: 4 7 a. Prior to recommendation of any adjustment in the level of care or denial of any inpatient 8 day provided by HOSPITAL CONTRACTOR that 5 does not meet Milliman criteriacontinuum of care criteria used by the CCU, the UMD 9 CCU shall notify HOSPITAL CONTRACTOR of a pending denial recommendation 6 within two (2) business days of such 10 determination. 7 11 b. HOSPITAL CONTRACTOR shall have the opportunity to provide written justification, within two 12 (2) 8 business days after receiving written notice of recommended denialrecommendation, to the UMD CCU which justification 9 may 13 include the application of Interqual criteria and/or other supporting information, as HOSPITAL 10 CONTRACTOR 14 deems necessary. 11 15 c. If the UMD CCU subsequently recommends the adjustment and/or denial of the inpatient day, HOSPITAL 16 CONTRACTOR shall 12 have the right to appeal the decision to the Medical Review Policy Committee, as 17 established by ADMINISTRATOR. 18 d. Intermediary shall reimburse hospital based on the determination of the CCU or Medical 19 Policy Committee as specified in Paragraph V. of 13 this Exhibit A to the Agreementappropriate. 14 20 3. Communicate with HOSPITAL CONTRACTOR regarding diversions, patient transfers, admissions, and 21 discharge planning. 15 22 4. Assist in coordinating the transitions of MSI MSN Patients to appropriate outpatient care, lower 16 23 levels of care or other needed services through COUNTY contracted providers for skilled nursing 24 facilities, 17 durable medical equipment and equipment, pharmacy services and through community-based providers for home 18 health care. 19 5. Conduct patient25 C. When needed services are not available through any Contracting Hospital, HOSPITALADMINISTRATOR 26 may negotiate separate Letters of Contract with rates appropriate for securing care for the provision of 27 such services with other Contracting ED Hospitals, and Other Provider education which shall includeor Non-Contract Hospitals, but including those that may 28 not be 20 limited to: 21 a. Availability of MSI Program services at locations other than UCI Medical Centerlocated in Orange County. 22 b. MSI Program services available at Community Clinics 23 c. Services for which pre-authorization 29 D. If a MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every reasonable 30 best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility that is recommended through the UMDoperated 31 by or has contracted with COUNTY to provide such acute psychiatric treatment. 24 C. Upon mutual written agreement32 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY may enter into separate agreements for Sub-Acute 25 shall 33 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR shall 34 perform its obligations under this Contract. The standards of medical care and professional duties of 35 CONTRACTOR’s employees providing Hospital Services for MSI Eligibles or MSI Patients. Execution of such agreements under this Contract shall be contingent upon 26 mutual written agreement regarding determined, as 36 applicable, by CONTRACTOR’s Board of Directors and the definition standards of sub-acute services, implementation, care in the community in which 37 // 1 CONTRACTOR is located and payment 27 proceduresall applicable provisions of law and other rules and 2 regulations of any and all governmental authorities relating to licensure and regulation of 3 CONTRACTOR. 28 D. 4 F. CONTRACTOR and ADMINISTRATOR may negotiate additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by mutually agree, in writing, to modify the MSI Program Medical Director, 30 and authorized in writing by ADMINISTRATOR, at a number 5 COUNTY Obligations Paragraph of Points negotiated bythis Exhibit A to the Contract. 6

County Obligations. 27 19 A. COUNTY ADMINISTRATOR shall provide oversight of the MSI MSN Program, including appropriate program 28 20 administration, coordination, planning, evaluation, financial and contract monitoring, public information 29 21 and referral, standards assurance, and review and analysis of data gathered and reported. Any 22 administrative duty or obligation to be performed pursuant to the Contract on a weekend or holiday may 23 be performed on the next regular business day. 30 24 B. COUNTY ADMINISTRATOR shall establish establish, either directly and/or through subcontract(s), a Utilization 31 Management Department Care 25 Coordination Unit (UMDCCU) which shall: 32 26 1. Coordinate and make arrangements for the medical needs and care of MSI EligiblesMSN Enrollees. The 33 UMD 27 CCU shall not be responsible for the coordination of the social services needs of such patients. 34 28 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 level 29 of care, and utilization of all services provided to MSI MSN Patients by All Providers. The parties 36 understand 30 that the UMD CCU shall use the latest available version of the Milliman Continuum of Of Care 37 Criteria Criteria, or other 31 appropriate criteria as approved by ADMINISTRATOR, as its guideline for such utilization review. COUNTY 32 ADMINISTRATOR acknowledges that HOSPITAL CONTRACTOR may use 1 Interqual criteria for similar purposes 33 within its own operations and with this understanding: 2 // 3 //: 4 34 a. Prior to recommendation of any adjustment in the level of care or denial of any inpatient 35 day provided by HOSPITAL CONTRACTOR that 5 does not meet Milliman criteriacontinuum of care criteria used by the CCU, the UMD 36 CCU shall notify HOSPITAL CONTRACTOR of a pending denial recommendation 6 within two (2) business days of such 37 determination. 7 1 b. HOSPITAL CONTRACTOR shall have the opportunity to provide written justification, within two 2 (2) 8 business days after receiving written notice of recommended denialrecommendation, to the UMD CCU which justification 9 may 3 include the application of Interqual criteria and/or other supporting information, as HOSPITAL 10 CONTRACTOR 4 deems necessary. 11 5 c. If the UMD CCU subsequently recommends the adjustment and/or denial of the inpatient day, HOSPITAL 6 CONTRACTOR shall 12 have the right to appeal the decision to the Medical Review Policy Committee, as 7 established by ADMINISTRATOR. 8 d. Intermediary shall reimburse hospital based on the determination of the CCU or Medical 9 Policy Committee as specified in Paragraph V. of 13 this Exhibit A to the Agreementappropriate. 14 10 3. Communicate with HOSPITAL CONTRACTOR regarding diversions, patient transfers, admissions, and 11 discharge planning. 15 12 4. Assist in coordinating the transitions of MSI MSN Patients to appropriate outpatient care, lower 16 13 levels of care or other needed services through COUNTY contracted providers for skilled nursing 14 facilities, 17 durable medical equipment and equipment, pharmacy services and through community-based providers for home 18 health care. 19 5. Conduct patient15 C. When needed services are not available through any Contracting Network Hospital, HOSPITAL16 ADMINISTRATOR may negotiate separate Letters of Contract with rates appropriate for securing care 17 for the provision of such services with other Contracting ED Hospitals, and Other Provider education which shall includeor Non-Contract Hospitals, but 18 including those that may not be located in Orange County. 19 D. If an MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every 20 limited to: reasonable best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility that 21 a. Availability of MSI Program services at locations other than UCI Medical Centeris operated by or has contracted with COUNTY to provide such acute psychiatric treatment. 22 b. MSI Program services available at Community Clinics E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY shall 23 c. neither have, nor exercise, any control or direction over the methods by which CONTRACTOR shall 24 perform its obligations under this Contract. The standards of medical care and professional duties of 25 CONTRACTOR’s employees providing Hospital Services for under this Contract shall be determined, as 26 applicable, by CONTRACTOR’s Board of Directors and the standards of care in the community in which pre-authorization 27 CONTRACTOR is recommended through the UMDlocated and all applicable provisions of law and other rules and 28 regulations of any and all governmental authorities relating to licensure and regulation of 29 CONTRACTOR. 24 C. Upon mutual written agreement, COUNTY may enter into separate agreements for Sub-Acute 25 Services for MSI Eligibles or MSI Patients. Execution of such agreements shall be contingent upon 26 mutual written agreement regarding the definition of sub-acute services, implementation, 30 F. CONTRACTOR and payment 27 procedures. 28 D. ADMINISTRATOR may negotiate additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by mutually agree, in writing, to modify the MSI Program Medical Director, 30 and authorized in writing by ADMINISTRATOR, at a number 31 COUNTY Obligations Paragraph of Points negotiated bythis Exhibit A to the Contract. 32

County Obligations. 27 7 A. COUNTY ADMINISTRATOR shall provide oversight of the MSI MSN Program, including appropriate program 28 8 administration, coordination, planning, evaluation, financial and contract monitoring, public information 29 9 and referral, standards assurance, and review and analysis of data gathered and reported. Any 10 administrative duty or obligation to be performed pursuant to the Contract on a weekend or holiday may 11 be performed on the next regular business day. 30 12 B. COUNTY ADMINISTRATOR shall establish establish, either directly and/or through subcontract(s), a Utilization 31 Management Department Care 13 Coordination Unit (UMDCCU) which shall: 32 14 1. Coordinate and make arrangements for the medical needs and care of MSI EligiblesMSN Enrollees. The 33 UMD 15 CCU shall not be responsible for the coordination of the social services needs of such patients. 34 16 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 level 17 of care, and utilization of all services provided to MSI MSN Patients by All Providers. The parties 36 understand that the UMD shall use the latest available version of the Milliman Continuum of Care 37 Criteria as its guideline for such utilization review. all COUNTY acknowledges that HOSPITAL may use 1 Interqual criteria for similar purposes within its own operations and with this understanding: 2 // 3 // 4 a. Prior to recommendation of denial of any inpatient day provided by HOSPITAL that 5 does not meet Milliman criteria, the UMD shall notify HOSPITAL of a pending denial recommendation 6 within two (2) business days of such determinationcontracted providers. 7 b. HOSPITAL shall have the opportunity to provide written justification, within two (2) 8 business days after receiving written notice of recommended denial, to the UMD which justification 9 may include the application of Interqual criteria and/or other supporting information, as HOSPITAL 10 deems necessary. 11 c. If the UMD subsequently recommends denial of the inpatient day, HOSPITAL shall 12 have the right to appeal the decision to the Medical Review Committee as specified in Paragraph V. of 13 this Exhibit A to the Agreement. 14 18 3. Communicate with HOSPITAL regarding diversions, admissions, and discharge planning. 15 4. Assist in coordinating the transitions of MSI Patients MSN Enrollees to appropriate outpatient care, lower 16 19 levels of care or needed services through COUNTY contracted providers for skilled nursing facilities, 17 20 durable medical equipment and equipment, pharmacy services and through community-based providers for home 18 health care. 19 521 C. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY shall 22 neither have, nor exercise, any control or direction over the methods by which CONTRACTOR shall 23 perform its obligations under the Contract. Conduct patientThe standards of medical care and professional duties of 24 CONTRACTOR’s employees providing Clinic Services under the Contract shall be determined, HOSPITALas 25 applicable, by CONTRACTOR’s Board of Directors and Other Provider education the standards of care in the community in which shall include, but not be 20 limited to: 21 a. Availability 26 CONTRACTOR is located and all applicable provisions of MSI Program services at locations law and other than UCI Medical Centerrules and 27 regulations of any and all governmental authorities relating to licensure and regulation of 28 CONTRACTOR. 22 b. MSI Program services available at Community Clinics 23 c. Services for which pre-authorization is recommended through the UMD. 24 C. Upon mutual written agreement, COUNTY may enter into separate agreements for Sub-Acute 25 Services for MSI Eligibles or MSI Patients. Execution of such agreements shall be contingent upon 26 mutual written agreement regarding the definition of sub-acute services, implementation, 29 D. CONTRACTOR and payment 27 procedures. 28 D. ADMINISTRATOR may negotiate additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by the MSI Program Medical Directormutually agree, 30 and authorized in writing by ADMINISTRATOR, at a number to modify the COUNTY 30 Obligations Paragraph of Points negotiated bythis Exhibit A to the Contract. 31

County Obligations. 27 18 A. COUNTY ADMINISTRATOR shall provide oversight of the MSI MSN Program, including appropriate 19 program 28 administration, coordination, planning, evaluation, financial and contract monitoring, public 20 information 29 and referral, standards assurance, and review and analysis of data gathered and reported. 21 Any administrative duty or obligation to be performed pursuant to the Agreement on a weekend or 22 holiday may be performed on the next regular business day. 30 23 B. COUNTY ADMINISTRATOR shall establish establish, either directly and/or through subcontract(s), a Utilization 31 Management Department Care 24 Coordination Unit (UMDCCU) which shall: 32 25 1. Coordinate and make arrangements for the medical needs and care of MSI EligiblesMSN Enrollees. The 33 UMD 26 CCU shall not be responsible for the coordination of the social services needs of such patients. 34 27 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 28 level of care, and utilization of all services provided to MSI MSN Patients by All Providers. The parties 36 understand that the UMD shall use the latest available version of the Milliman Continuum of Care 37 Criteria as its guideline for such utilization review. COUNTY acknowledges that HOSPITAL may use 1 Interqual criteria for similar purposes within its own operations and with this understanding: 2 // 3 // 4 a. Prior to recommendation of denial of any inpatient day provided by HOSPITAL that 5 does not meet Milliman criteria, the UMD shall notify HOSPITAL of a pending denial recommendation 6 within two (2) business days of such determination. 7 b. HOSPITAL shall have the opportunity to provide written justification, within two (2) 8 business days after receiving written notice of recommended denial, to the UMD which justification 9 may include the application of Interqual criteria and/or other supporting information, as HOSPITAL 10 deems necessary. 11 c. If the UMD subsequently recommends denial of the inpatient day, HOSPITAL shall 12 have the right to appeal the decision to the Medical Review Committee as specified in Paragraph V. of 13 this Exhibit A to the Agreement. 14 29 3. Communicate with HOSPITAL regarding diversions, admissions, and discharge planning. 15 4. Assist in coordinating the transitions of MSI Patients MSN Enrollees to appropriate outpatient care, 30 lower 16 levels of care or needed services through COUNTY contracted providers for skilled nursing 31 facilities, 17 durable medical equipment and equipment, pharmacy services and through community-based providers for home 18 health care. 19 532 C. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY 33 shall neither have, nor exercise, any control or direction over the methods by which CONTRACTOR 34 shall perform its obligations under the Agreement. Conduct patientThe standards of medical care and professional 35 duties of CONTRACTOR’s employees providing Clinic Services under the Agreement shall be 36 determined, HOSPITALas applicable, by CONTRACTOR’s Board of Directors and Other Provider education the standards of care in the 37 community in which shall include, but not be 20 limited to: 21 a. Availability CONTRACTOR is located and all applicable provisions of MSI Program services at locations law and other than UCI Medical Centerrules and 1 regulations of any and all governmental authorities relating to licensure and regulation of 2 CONTRACTOR. 22 b. MSI Program services available at Community Clinics 23 c. Services for which pre-authorization is recommended through the UMD. 24 C. Upon mutual written agreement, COUNTY may enter into separate agreements for Sub-Acute 25 Services for MSI Eligibles or MSI Patients. Execution of such agreements shall be contingent upon 26 mutual written agreement regarding the definition of sub-acute services, implementation, 3 D. CONTRACTOR and payment 27 procedures. 28 D. ADMINISTRATOR may negotiate additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by the MSI Program Medical Directormutually agree, 30 and authorized in writing by ADMINISTRATORwriting, at a number of Points negotiated byto modify the

County Obligations. 27 11 A. COUNTY ADMINISTRATOR shall provide oversight of the MSI MSN Program, including appropriate 12 program 28 administration, coordination, planning, evaluation, financial and contract monitoring, public 13 information 29 and referral, standards assurance, and review and analysis of data gathered and reported. 30 14 B. COUNTY ADMINISTRATOR shall establish establish, either directly and/or through subcontract(s), a Utilization 31 Management Department (UMD) CCU which shall: 32 1. Coordinate 15 shall coordinate and make arrangements for the medical needs and care of MSI Eligibles. The 33 UMD shall not be responsible for the coordination of social services needs of such patients. 34 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 level of care, and utilization of all services provided to MSI Patients by All Providers. The parties 36 understand that the UMD shall use the latest available version of the Milliman Continuum of Care 37 Criteria as its guideline for such utilization review. COUNTY acknowledges that HOSPITAL may use 1 Interqual criteria for similar purposes within its own operations and with this understanding: 2 // 3 // 4 a. Prior to recommendation of denial of any inpatient day provided by HOSPITAL that 5 does not meet Milliman criteria, the UMD shall notify HOSPITAL of a pending denial recommendation 6 within two (2) business days of such determination. 7 b. HOSPITAL shall have the opportunity to provide written justification, within two (2) 8 business days after receiving written notice of recommended denial, to the UMD which justification 9 may include the application of Interqual criteria and/or other supporting information, as HOSPITAL 10 deems necessary. 11 c. If the UMD subsequently recommends denial of the inpatient day, HOSPITAL shall 12 have the right to appeal the decision to the Medical Review Committee MSN Enrollees as specified in 16 Paragraph V. III of 13 this Exhibit A to the Agreement. 14 317 C. ADMINISTRATOR shall direct the CCU to work with CONTRACTOR to develop reporting 18 and information sharing activities to address the following: 19 1. Communicate with HOSPITAL regarding diversions, admissions, and discharge planningDeny claims based on recommendations from the CCU. 15 420 2. Assist Coordinate collection and evaluation of data by CONTRACTOR and the CCU. 21 D. When needed services are not available through any Contracting Hospital, ADMINISTRATOR 22 may negotiate separate Letters of Agreement with rates appropriate for securing care for the provision of 23 such services with Non-Contract Hospitals and providers, including those that may not be located in coordinating the transitions of MSI Patients to appropriate outpatient 24 Orange County. 25 E. If an MSN Enrollee requires acute psychiatric care, lower 16 levels ADMINISTRATOR will make every 26 reasonable effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility that is 27 operated by or needed services through has contracted with COUNTY contracted providers for skilled nursing facilities, 17 durable medical equipment and pharmacy services and through community-based providers for home 18 health care. 19 5. Conduct patient, HOSPITAL, and Other Provider education which shall include, but not be 20 limited to: 21 a. Availability of MSI Program services at locations other than UCI Medical Center. 22 b. MSI Program services available at Community Clinics 23 c. Services for which pre-authorization is recommended through the UMD. 24 C. Upon mutual written agreement, COUNTY may enter into separate agreements for Sub-Acute 25 Services for MSI Eligibles or MSI Patients. Execution of to provide such agreements shall be contingent upon 26 mutual written agreement regarding the definition of sub-acute services, implementation, and payment 27 procedurespsychiatric treatment. 28 D. F. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY 29 shall neither have, nor exercise, any control or direction over the methods by which Physicians and 30 Other Providers shall perform their obligations under the Agreement. The standards of medical care and 31 professional duties of Physician’s and Other Provider’s employees providing Medical Services under the 32 Agreement shall be determined, as applicable, by Physician’s and Other Provider’s Board of Directors 33 and the standards of care in the community in which Physician and Other Providers are located and all 34 applicable provisions of law and other rules and regulations of any and all governmental authorities 35 relating to licensure and regulation of Physician and Other Providers. 36 G. Any administrative duty or obligation to be performed pursuant to the Agreement on a weekend 37 or holiday may be performed on the next regular business day. 1 H. CONTRACTOR and ADMINISTRATOR may negotiate additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by mutually agree, in writing, to modify the MSI Program Medical Director, 30 and authorized in writing by ADMINISTRATOR, at a number 2 COUNTY Obligations Paragraph of Points negotiated bythis Exhibit A to the Agreement. 3

County Obligations. 27 15 A. COUNTY ADMINISTRATOR shall provide oversight of the MSI ProgramProgram throughout the term of the 16 Agreement, including appropriate program 28 administration, coordination, planning, evaluation, financial 17 and contract monitoring, public information 29 and referral, standards assurance, and review and analysis of 18 data gathered and reported. 30 19 1. ADMINISTRATOR shall notify CLINIC, immediately upon becoming aware of any 20 amendments, modifications, changes, or updates to the STCs or the LIHP Agreement. When available, 21 ADMINISTRATOR shall provide CLINIC with a copy of the STCs and the LIHP Agreement, including 22 any written amendments, modifications, changes or updates. 23 2. Any administrative duty or obligation to be performed pursuant to the Agreement on a 24 weekend or holiday may be performed on the next regular business day. 25 B. COUNTY ADMINISTRATOR, throughout the term of the Agreement, shall establish establish, either directly 26 and/or through subcontract(s), a Utilization 31 Management Department (UMD) which shall: 32 27 1. Coordinate and make arrangements for the medical needs and care of MSI Eligibles. The 33 28 UMD shall not be responsible for the coordination of the social services needs of such patients. 34 29 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 30 level of care, and utilization of all services provided to MSI Patients by All Providers. The parties 36 understand that the UMD shall use the latest available version of the Milliman Continuum of Care 37 Criteria as its guideline for such utilization review. COUNTY acknowledges that HOSPITAL may use 1 Interqual criteria for similar purposes within its own operations and with this understanding: 2 // 3 // 4 a. Prior to recommendation of denial of any inpatient day provided by HOSPITAL that 5 does not meet Milliman criteria, the UMD shall notify HOSPITAL of a pending denial recommendation 6 within two (2) business days of such determination. 7 b. HOSPITAL shall have the opportunity to provide written justification, within two (2) 8 business days after receiving written notice of recommended denial, to the UMD which justification 9 may include the application of Interqual criteria and/or other supporting information, as HOSPITAL 10 deems necessary. 11 c. If the UMD subsequently recommends denial of the inpatient day, HOSPITAL shall 12 have the right to appeal the decision to the Medical Review Committee as specified in Paragraph V. of 13 this Exhibit A to the Agreement. 14 31 3. Communicate with HOSPITAL regarding diversions, admissions, and discharge planning. 15 4. Assist in coordinating the transitions of MSI Patients Eligibles to appropriate outpatient care, lower 16 32 levels of care or needed services through COUNTY contracted providers for skilled nursing facilities, 17 durable medical equipment 33 and pharmacy services and through community-based providers for home 18 health care. 19 534 4. Conduct patient, HOSPITAL, patient and Other Provider health care provider education which shall include, but not be 20 limited 35 to: 21 36 a. Availability of MSI Program services at locations other than UCI Medical Center. 22 37 b. MSI Program services available at Community Contracting Clinics. 23 1 c. Services for which pre-authorization is recommended through the UMD. 24 2 C. Upon mutual written agreement, COUNTY ADMINISTRATOR may enter into separate agreements letters of agreement for Sub-Acute 25 Dental Services for MSI Eligibles that cannot 3 be provided by Contracting Clinics. 4 D. COUNTY shall neither have, nor exercise, any control or MSI Patientsdirection over the methods by which 5 CLINIC shall perform its obligations under the Agreement. Execution The standards of such agreements medical care and 6 professional duties of CLINIC’s employees providing Clinic and/or Dental Services under the 7 Agreement shall be contingent upon 26 mutual written agreement regarding determined, as applicable, by CLINIC’s Board of Directors and the definition standards of sub-acute services, implementation, care 8 in the community in which CLINIC is located and payment 27 procedures. 28 D. ADMINISTRATOR may negotiate additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by the MSI Program Medical Director, 30 all applicable provisions of law and authorized in writing by ADMINISTRATOR, at a number other rules and 9 regulations of Points negotiated byany and all governmental authorities relating to licensure and regulation of CLINIC. 10

County Obligations. 27 16 A. COUNTY ADMINISTRATOR shall provide oversight of the MSI MSN Program, including appropriate 17 program 28 administration, coordination, planning, evaluation, financial and contract monitoring, public 18 information 29 and referral, standards assurance, and review and analysis of data gathered and reported. 19 Any administrative duty or obligation to be performed pursuant to the Agreement on a weekend or 20 holiday may be performed on the next regular business day. 30 21 B. COUNTY ADMINISTRATOR shall establish establish, either directly and/or through subcontract(s), a Utilization 31 Management Department Care 22 Coordination Unit (UMDCCU) which shall: 32 23 1. Coordinate and make arrangements for the medical needs and care of MSI EligiblesMSN Enrollees. The 33 UMD 24 CCU shall not be responsible for the coordination of the social services needs of such patients. 34 25 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 26 level of care, and utilization of all services provided to MSI MSN Patients by All Providers. The parties 36 27 understand that the UMD CCU shall use the latest available version of the Milliman Continuum of Care 37 Criteria 28 Criteria, or other appropriate criteria as approved by ADMINISTRATOR, as its guideline for such 29 utilization review. COUNTY ADMINISTRATOR acknowledges that HOSPITAL CONTRACTOR may use 1 Interqual criteria 30 for similar purposes within its own operations and with this understanding: 2 // 3 //: 4 31 a. Prior to recommendation of any adjustment in the level of care or denial of any 32 inpatient day provided by HOSPITAL CONTRACTOR that 5 does not meet Milliman criteria, the UMD CCU shall notify HOSPITAL 33 CONTRACTOR of a pending denial recommendation 6 within two (2) business days of such determination. 7 34 b. HOSPITAL CONTRACTOR shall have the opportunity to provide written justification, within two 35 (2) 8 business days after receiving written notice of recommended denialrecommendation, to the UMD CCU which justification 9 may 36 include the application of Interqual criteria and/or other supporting information, as HOSPITAL 10 CONTRACTOR 37 deems necessary. 11 1 c. If the UMD CCU subsequently recommends the adjustment and/or denial of the inpatient day, HOSPITAL 2 CONTRACTOR shall 12 have the right to appeal the decision to the Medical Review Policy Committee as specified in Paragraph V. of 13 this Exhibit A to the Agreement3 established by ADMINISTRATOR. 14 4 d. Intermediary shall reimburse hospital based on the determination of the CCU or 5 Medical Policy Committee as appropriate. 6 3. Communicate with HOSPITAL CONTRACTOR regarding diversions, patient transfers, admissions, 7 and discharge planning. 15 8 4. Assist in coordinating the transitions transition of MSI MSN Patients to appropriate outpatient care, lower 16 9 levels of care or other needed services through COUNTY contracted providers for skilled nursing 10 facilities, 17 durable medical equipment and equipment, pharmacy services and through community-based providers for home 18 health care. 19 5. Conduct patient11 C. When needed services are not available through any Contracting Hospital, HOSPITALADMINISTRATOR 12 may negotiate separate Letters of Agreement with rates appropriate for securing care for the provision of 13 such services with Non-Contract Hospitals, and Other Provider education which shall include, but including those that may not be 20 limited to: 21 a. Availability of MSI Program services at locations other than UCI Medical Centerlocated in Orange County. 22 b. MSI Program services available at Community Clinics 23 c. Services for which pre-authorization 14 D. If an MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every 15 reasonable best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility 16 that is recommended through the UMDoperated by or has contracted with COUNTY to provide such acute psychiatric treatment. 24 C. Upon mutual written agreement17 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY may enter into separate agreements for Sub-Acute 25 18 shall neither have, nor exercise, any control or direction over the methods by which CONTRACTOR 19 shall perform its obligations under the Agreement. The standards of medical care and professional 20 duties of CONTRACTOR’s employees providing Hospital Services for MSI Eligibles or MSI Patients. Execution of such agreements under the Agreement shall be contingent upon 26 mutual written agreement regarding 21 determined, as applicable, by CONTRACTOR’s Board of Directors and the definition standards of sub-acute services, implementation, care in the 22 community in which CONTRACTOR is located and payment 27 procedures. 28 D. ADMINISTRATOR may negotiate additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by the MSI Program Medical Director, 30 all applicable provisions of law and authorized in writing by ADMINISTRATOR, at a number other rules and 23 regulations of Points negotiated byany and all governmental authorities relating to licensure and regulation of 24 CONTRACTOR. 25

County Obligations. 27 31 A. COUNTY ADMINISTRATOR shall provide oversight of the MSI MSN Program, including appropriate 32 program 28 administration, coordination, planning, evaluation, financial and contract monitoring, public 33 information 29 and referral, standards assurance, and review and analysis of data gathered and reported. 34 Any administrative duty or obligation to be performed pursuant to this Agreement on a weekend or 35 holiday may be performed on the next regular business day. 30 36 B. COUNTY ADMINISTRATOR shall establish establish, either directly and/or through subcontract(s), a Utilization 31 Management Department Care 37 Coordination Unit (UMDCCU) which shall: 32 1 1. Coordinate and make arrangements for the medical needs and care of MSI EligiblesMSN Enrollees. The 33 UMD 2 CCU shall not be responsible for the coordination of the social services needs of such patients. 34 3 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 4 level of care, and utilization of all services provided to MSI MSN Patients by All Providers. The parties 36 5 understand that the UMD CCU shall use the latest available version of the Milliman Continuum of Care 37 Criteria 6 Criteria, or other appropriate criteria as approved by ADMINISTRATOR, as its guideline for such 7 utilization review. COUNTY ADMINISTRATOR acknowledges that HOSPITAL CONTRACTOR may use 1 Interqual criteria 8 for similar purposes within its own operations and with this understanding: 2 // 3 //: 4 9 a. Prior to recommendation of any adjustment in the level of care or denial of any 10 inpatient day provided by HOSPITAL CONTRACTOR that 5 does not meet Milliman criteriacontinuum of care criteria used by the 11 CCU, the UMD CCU shall notify HOSPITAL CONTRACTOR of a pending denial recommendation 6 within two (2) business days 12 of such determination. 7 13 b. HOSPITAL CONTRACTOR shall have the opportunity to provide written justification, within two 14 (2) 8 business days after receiving written notice of recommended denialrecommendation, to the UMD CCU which justification 9 may 15 include the application of Interqual criteria and/or other supporting information, as HOSPITAL 10 CONTRACTOR 16 deems necessary. 11 17 c. If the UMD CCU subsequently recommends the adjustment and/or denial of the inpatient day, HOSPITAL 18 CONTRACTOR shall 12 have the right to appeal the decision to the Medical Review Policy Committee, as 19 established by ADMINISTRATOR. 20 d. Intermediary shall reimburse hospital based on the determination of the CCU or 21 Medical Policy Committee as specified in Paragraph V. of 13 this Exhibit A to the Agreementappropriate. 14 22 3. Communicate with HOSPITAL CONTRACTOR regarding diversions, patient transfers, admissions, and 23 discharge planning. 15 24 4. Assist in coordinating the transitions of MSI MSN Patients to appropriate outpatient care, lower 16 25 levels of care or other needed services through COUNTY contracted providers for skilled nursing 26 facilities, 17 durable medical equipment and equipment, pharmacy services and through community-based providers for home 18 health care. 19 5. Conduct patient27 C. When needed services are not available through any Contracting Hospital, HOSPITALADMINISTRATOR 28 may negotiate separate Letters of Agreement with rates appropriate for securing care for the provision of 29 such services with other Contracting Hospitals, and Other Provider education which shall includeor Non-Contract Hospitals, but including those that may not 30 be 20 limited to: 21 a. Availability of MSI Program services at locations other than UCI Medical Centerlocated in Orange County. 22 b. MSI Program services available at Community Clinics 23 c. Services for which pre-authorization 31 D. If an MSN Enrollee requires acute psychiatric care, ADMINISTRATOR will make every 32 reasonable best effort to facilitate the transfer of the MSN Enrollee to a hospital or health care facility 33 that is recommended through the UMDoperated by or has contracted with COUNTY to provide such acute psychiatric treatment. 24 C. Upon mutual written agreement34 E. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY may enter into separate agreements for Sub-Acute 25 35 shall neither have, nor exercise, any control or direction over the methods by which CONTRACTOR 36 shall perform its obligations under this Agreement. The standards of medical care and professional 37 duties of CONTRACTOR’s employees providing Hospital Services for MSI Eligibles or MSI Patients. Execution of such agreements under this Agreement shall be contingent upon 26 mutual written agreement regarding 1 determined, as applicable, by CONTRACTOR’s Board of Directors and the definition standards of sub-acute services, implementation, care in the 2 community in which CONTRACTOR is located and payment 27 proceduresall applicable provisions of law and other rules and 3 regulations of any and all governmental authorities relating to licensure and regulation of 4 CONTRACTOR. 28 D. 5 F. CONTRACTOR and ADMINISTRATOR may negotiate additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by mutually agree, in writing, to modify the MSI Program Medical Director, 30 and authorized in writing by ADMINISTRATOR, at a number 6 COUNTY Obligations Paragraph of Points negotiated bythis Exhibit A to the Agreement. 7

County Obligations. 27 18 A. COUNTY ADMINISTRATOR shall provide oversight of the MSI MSN Program, including appropriate 19 program 28 administration, coordination, planning, evaluation, financial and contract monitoring, public 20 information 29 and referral, standards assurance, and review and analysis of data gathered and reported. 21 Any administrative duty or obligation to be performed pursuant to the Agreement on a weekend or 22 holiday may be performed on the next regular business day. 30 23 B. COUNTY ADMINISTRATOR shall establish establish, either directly and/or through subcontract(s), a Utilization 31 Management Department Care 24 Coordination Unit (UMDCCU) which shall: 32 25 1. Coordinate and make arrangements for the medical needs and care of MSI EligiblesMSN Enrollees. The 33 UMD 26 CCU shall not be responsible for the coordination of the social services needs of such patients. 34 27 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 28 level of care, and utilization of all services provided to MSI MSN Patients by All Providers. The parties 36 understand that the UMD shall use the latest available version of the Milliman Continuum of Care 37 Criteria as its guideline for such utilization review. COUNTY acknowledges that HOSPITAL may use 1 Interqual criteria for similar purposes within its own operations and with this understanding: 2 // 3 // 4 a. Prior to recommendation of denial of any inpatient day provided by HOSPITAL that 5 does not meet Milliman criteria, the UMD shall notify HOSPITAL of a pending denial recommendation 6 within two (2) business days of such determination. 7 b. HOSPITAL shall have the opportunity to provide written justification, within two (2) 8 business days after receiving written notice of recommended denial, to the UMD which justification 9 may include the application of Interqual criteria and/or other supporting information, as HOSPITAL 10 deems necessary. 11 c. If the UMD subsequently recommends denial of the inpatient day, HOSPITAL shall 12 have the right to appeal the decision to the Medical Review Committee as specified in Paragraph V. of 13 this Exhibit A to the Agreement. 14 29 3. Communicate with HOSPITAL regarding diversions, admissions, and discharge planning. 15 4. Assist in coordinating the transitions of MSI Patients MSN Enrollees to appropriate outpatient care, 30 lower 16 levels of care or needed services through COUNTY contracted providers for skilled nursing 31 facilities, 17 durable medical equipment and equipment, pharmacy services and through community-based providers for home 18 health care. 19 532 C. Except as provided herein with respect to discrimination of care to MSN Patients, COUNTY 33 shall neither have, nor exercise, any control or direction over the methods by which CONTRACTOR 34 shall perform its obligations under the Agreement. Conduct patientThe standards of medical care and professional 35 duties of CONTRACTOR’s employees providing Clinic Services under the Agreement shall be 36 determined, HOSPITALas applicable, by CONTRACTOR’s Board of Directors and Other Provider education the standards of care in the 37 community in which shall include, but not be 20 limited to: 21 a. Availability CONTRACTOR is located and all applicable provisions of MSI Program services at locations law and other than UCI Medical Centerrules and 1 regulations of any and all governmental authorities relating to licensure and regulation of 2 CONTRACTOR. 22 b. MSI Program services available at Community Clinics 23 c. Services for which pre-authorization is recommended through the UMD. 24 C. Upon mutual written agreement, COUNTY may enter into separate agreements for Sub-Acute 25 Services for MSI Eligibles or MSI Patients. Execution of such agreements shall be contingent upon 26 mutual written agreement regarding the definition of sub-acute services, implementation, 3 D. CONTRACTOR and payment 27 procedures. 28 D. ADMINISTRATOR may negotiate additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by mutually agree, in writing, to modify the MSI Program Medical Director, 30 and authorized in writing by ADMINISTRATOR, at a number 4 COUNTY Obligations Paragraph of Points negotiated bythis Exhibit A to the Agreement. 5