Common use of Other Administrative Components Clause in Contracts

Other Administrative Components. The CHC-MCO must provide for each of the administrative functions listed below: • A Quality Management/Quality Improvement Coordinator who is a Pennsylvania-licensed physician, RN, or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department’s EQR contractor. • A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the CHC-MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Participant care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement requirements and coordinate with the BH-MCO to effectuate the requirements. • A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing Providers with prompt resolution of their problems or inquiries and appropriate education about participation in CHC and maintaining a sufficient Network. Individual Provider representatives will report directly to the Director of Network Management. • A UM Coordinator who is a Pennsylvania-licensed physician, RN or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to UM in lieu of professional licensure. • A Director of Service Coordination who oversees all Service Coordination functions of the CHC plan and who shall have the qualifications of a Service Coordinator and a minimum of five (5) years of management/supervisory experience in the healthcare field. The Director of Service Coordination is responsible for all Service Coordination functions, whether the CHC-MCO provides all Service Coordinator functions in house or contracts with outside entities to meet Service Coordination requirements. • A Government Xxxxxxx who serves as the Department’s primary point of contact with the CHC-MCO for day-to-day management of contractual and operational issues. The CHC-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is notavailable. • A Participant Services Manager who oversees staff to coordinate communications with Participants and enables Participants to receive prompt resolution of their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the CHC-MCO and its Network Providers. There must be sufficient staff in CHC-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers (e.g., HCBS Providers and Participant-Directed Services Providers) regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available CHC-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the CHC-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Participants throughout the Complaint, Grievance and DHS Fair Hearing processes. • A Claims Administrator who oversees staff to provide for the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the CHC-MCO. • A Contract Compliance Officer who monitors the CHC-MCO’s compliance with all the requirements of the Agreement. The CHC-MCO must ensure all staff have appropriate training, education, experience, and orientation to fulfill the requirements of their position and maintain documentation of completion. The CHC-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The CHC-MCO’s staffing should represent the racial, ethnic, and cultural diversity of the Participants being served by CHC and comply with all requirements of Exhibit B, Standard Terms and Conditions for Services. The Cultural Competency may be reflected by the CHC-MCO’s pursuit to: • Identify and value differences. • Acknowledge the interactive dynamics of cultural differences. • Continually expand cultural knowledge and resources with regard to the populations served. • Recruit racial and ethnic minority staff in proportion to the populations served. • Collaborate with the community regarding service provisions and delivery. • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The CHC-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement and include in its organizational structure the components outlined in this Agreement. The CHC-MCO must staff these functions with qualified persons in numbers appropriate to the CHC-MCO's size of Enrollment. The Department will determine whether or not the CHC-MCO is in compliance. The CHC-MCO may contract with a third party to perform one (1) or more of its functions, subject to the subcontractor conditions described in Section XII, Subcontractual Relationships. The CHC-MCO is required to keep the Department informed at all times of the management individuals whose duties include each of the responsibilities outlined in this section.

Other Administrative Components. The CHCPH-MCO must provide for each of the administrative functions listed below: . For those positions not indicated as full time, the PH-MCO may combine or split the functions as long as the PH-MCO can demonstrate that the duties of these functions conform to the Agreement requirements. • A Quality Management/Quality Improvement QM Coordinator who is a Pennsylvania-licensed physician, RN, registered nurse or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the The Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department’s EQR contractor. • A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the CHCPH-MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Participant Member care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement requirements and coordinate with the BH-MCO to effectuate the requirements. • A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing Providers with prompt resolution of their problems or inquiries and appropriate education about participation in CHC and maintaining a sufficient Network. Individual Provider representatives will report directly to the Director of Network Management. • A UM Coordinator who is a Pennsylvania-licensed physician, RN registered nurse or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the The Department may consider other advanced degrees relevant to UM in lieu of professional licensure. • A Director of Service Coordination full-time SNU Coordinator who oversees all Service Coordination functions of is a Pennsylvania-licensed or certified medical professional (or other health related license or certification), or has a bachelor’s degree in social work, teaching, or human services. In addition, the CHC plan and who shall individual must have the qualifications of a Service Coordinator and a minimum of five (5) three years of management/supervisory past experience in the healthcare fielddealing with special needs populations similar to those served by MA. The SNU Coordinator must have access to and periodically consult with the PH-MCO’s Medical Director of Service Coordination is responsible and must work in close collaboration with the SNU and SNU staff. The SNU Coordinator must have access to the PH-MCOs Dental Director for all Service Coordination functions, whether the CHCissues related to dental services. The PH-MCO provides all Service Coordinator functions will notify the Department within thirty (30) days of a change in house or contracts with outside entities to meet Service Coordination requirementsthe SNU Coordinator. • A full-time Government Xxxxxxx who serves as the Department’s primary point of contact with the CHCPH-MCO for the day-to-day management of contractual and operational issues. The CHCPH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is notavailablenot available. • A Participant Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Participants Members and enables Participants act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution of to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the CHCPH-MCO and its Network Providers. There must be sufficient staff in CHCPH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competenciescompetencies • A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers (e.g., HCBS Providers and Participant-Directed Services Providers) regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available CHCPH-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the CHCPH-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Participants throughout the Complaint, Grievance and DHS Fair Hearing processes. • A Claims Administrator who oversees staff to provide for the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the CHC-MCO. • A Contract Compliance Officer who monitors ensures that the CHCPH-MCO’s MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS® Project Manager who acts as the point person with the Department and the Department’s EQR contractor. • A Special Investigations Unit (SIU) Director who serves as the Department’s primary contact for program integrity functions. The CHCSIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience, experience and orientation to fulfill the requirements of their the position and maintain documentation of completion. The CHCPH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The CHCPH-MCO’s staffing should represent the racial, ethnic, ethnic and cultural diversity of the Participants being served by CHC Program and comply with all requirements of Exhibit BD, Standard Terms and Conditions for Services. The Cultural Competency may be reflected by the CHCPH-MCO’s pursuit to: • Identify and value differences. ; • Acknowledge the interactive dynamics of cultural differences. ; • Continually expand cultural knowledge and resources with regard to the populations served. ; • Recruit racial and ethnic minority staff in proportion to the populations served. ; • Collaborate with the community regarding service provisions and delivery. ; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The CHCPH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement and Agreement. The PH-MCO must include in its organizational structure structure, the components outlined in this the Agreement. The CHC-MCO functions must staff these functions with be staffed by qualified persons in numbers appropriate to the CHCPH-MCO's size of Enrollment. The Department will determine has the right to make the final determination regarding whether or not the CHCPH-MCO is in compliance. The CHCPH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of its these functions, subject to the subcontractor Subcontractor conditions described in Section XII, Subcontractual Relationships. The CHCPH-MCO is required to keep the Department informed at all times of the management individuals individual(s) whose duties include each of the responsibilities outlined in this section.

Other Administrative Components. The CHC-MCO must provide for each of the administrative functions listed below: •  A Quality Management/Quality Improvement Coordinator who is a Pennsylvania-licensed physician, RN, or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department’s EQR contractor. •  A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the CHC-MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Participant care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement requirements and coordinate with the BH-MCO to effectuate the requirements. •  A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing Providers with prompt resolution of their problems or inquiries and appropriate education about participation in CHC and maintaining a sufficient Network. Individual Provider representatives will report directly to the Director of Network Management. •  A UM Coordinator who is a Pennsylvania-licensed physician, RN or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to UM in lieu of professional licensure. • A Director of Service Coordination who oversees all Service Coordination functions of the CHC plan and who shall have the qualifications of a Service Coordinator and a minimum of five (5) years of management/supervisory experience in the healthcare field. The Director of Service Coordination is responsible for all Service Coordination functions, whether the CHC-MCO provides all Service Coordinator functions in house or contracts with outside entities to meet Service Coordination requirements. •  A Government Xxxxxxx who serves as the Department’s primary point of contact with the CHC-MCO for day-to-day management of contractual and operational issues. The CHC-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is notavailable. •  A Participant Services Manager who oversees staff to coordinate communications with Participants and enables Participants to receive prompt resolution of their issues, problems or inquiries. •  A Provider Services Manager who oversees staff to coordinate communications between the CHC-MCO and its Network Providers. There must be sufficient staff in CHC-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies. •  A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers (e.g., HCBS Providers and Participant-Directed Services Providers) regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available CHC-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the CHC-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. •  A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Participants throughout the Complaint, Grievance and DHS Fair Hearing processes. •  A Claims Administrator who oversees staff to provide for the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the CHC-MCO. • A Contract Compliance Officer who monitors the CHC-MCO’s compliance with all the requirements of the Agreement. The CHC-MCO must ensure all staff have appropriate training, education, experience, and orientation to fulfill the requirements of their position and maintain documentation of completion. The CHC-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The CHC-MCO’s staffing should represent the racial, ethnic, and cultural diversity of the Participants being served by CHC and comply with all requirements of Exhibit B, Standard Terms and Conditions for Services. The Cultural Competency may be reflected by the CHC-MCO’s pursuit to: • Identify and value differences. • Acknowledge the interactive dynamics of cultural differences. • Continually expand cultural knowledge and resources with regard to the populations served. • Recruit racial and ethnic minority staff in proportion to the populations served. • Collaborate with the community regarding service provisions and delivery. • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The CHC-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement and include in its organizational structure the components outlined in this Agreement. The CHC-MCO must staff these functions with qualified persons in numbers appropriate to the CHC-MCO's size of Enrollment. The Department will determine whether or not the CHC-MCO is in compliance. The CHC-MCO may contract with a third party to perform one (1) or more of its functions, subject to the subcontractor conditions described in Section XII, Subcontractual Relationships. The CHC-MCO is required to keep the Department informed at all times of the management individuals whose duties include each of the responsibilities outlined in this section.

Other Administrative Components. ‌ The CHC-MCO must provide for each of the administrative functions listed below: • . For those positions not indicated as full time, the CHC-MCO may combine or split the functions as long as the CHC-MCO can demonstrate that the duties of these functions conform to the agreement requirements.‌  A Quality Management/Quality Improvement (QM/QI) Coordinator who is a Pennsylvania-licensed physician, RN, registered nurse or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the The Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the the‌ Department’s EQR contractor. •  A BH Behavioral Health Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor ensure that the CHC-MCO for adherence adhere to BH behavioral health requirements in this Agreementagreement. The primary functions of the BH Behavioral Health Coordinator are: are:‌ • Coordinate Participant behavioral care needs with BH behavioral health Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH behavioral health Providers. • Participate in the identification of best practices for BH behavioral health in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement requirements and coordinate with the BH-MCO to effectuate the requirements. •  A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing ensures that Providers with receive prompt resolution of to their problems or inquiries and inquiries, appropriate education about participation in the CHC program and maintaining maintain a sufficient Provider Network. Individual Provider representatives will are expected to report directly to the Director of Network Management. • Management.‌  A UM Coordinator who is a Pennsylvania-licensed physician, RN registered nurse or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the The Department may consider other advanced degrees relevant to UM in lieu of professional licensure. • licensure.‌  A full-time Director of Service Coordination who oversees all Service Coordination functions of the CHC plan and who shall have the qualifications of a Service Coordinator and a minimum of five (5) years of management/supervisory experience in the healthcare field. The Director of Service Coordination is responsible for all Service Coordination functions, whether the CHC-MCO provides all Service Coordinator functions in house or contracts with outside entities to meet Service Coordination requirements. • requirements.‌  A full-time Government Xxxxxxx Liaison who serves as the Department’s primary point of contact with the CHC-MCO for day-to-day management of contractual and operational issues. The CHC-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is notavailable. • not available.‌  A Participant Services Manager who oversees staff to coordinate communications with Participants and enables Participants to receive prompt resolution of their issues, problems or inquiries. • inquiries.‌  A Provider Services Manager who oversees staff to coordinate coordinate‌ communications between the CHC-MCO and its Network Providers. There must be sufficient staff in CHC-MCO Provider Servicesservices, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies. • competencies.‌  A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: are:‌ • Educate contracted and non-contracted Providers (e.g., e.g. HCBS Providers and Participant-Directed Services Providers) regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available CHC-MCO resources such as Provider manuals, website, fee schedules, etc. etc.‌ • Interface with the CHC-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently Frequently communicate (i.e., telephonic and on-site) with Providers to provide for assure the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. •  A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Participants throughout the Complaint, Grievance and DHS Fair Hearing processes. • processes.‌  A Claims Administrator who oversees staff to provide for ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement agreement requirements and the efficient management of the CHC-MCO. • MCO.‌  A Contract Compliance Officer who monitors ensures that the CHC-MCO’s MCO is in compliance with all the requirements of the Agreement. The agreement.‌ All CHC-MCO staff must ensure all staff have appropriate training, education, experience, and orientation to fulfill the requirements of their position and maintain documentation of completionthe position. The CHC-MCO must update job descriptions for each of the positions if responsibilities for these positions change. change.‌ The CHC-MCO’s staffing should represent the racial, ethnic, and cultural diversity of the Participants being served by CHC and comply with all requirements of Exhibit BD, Standard Terms and Conditions for Services. The Cultural Competency may be reflected by the CHC-MCO’s pursuit to: • to:‌  Identify and value differences. • differences.‌  Acknowledge the interactive dynamics of cultural differences. • differences.‌  Continually expand cultural knowledge and resources with regard to the populations served. • served.‌  Recruit racial and ethnic minority staff in proportion to the populations served. • served.‌  Collaborate with the community regarding service provisions and delivery. • delivery.‌  Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. served.‌ The CHC-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement and include in its organizational structure the components outlined in this Agreementagreement. The CHC-MCO must staff these include in its organizational structure, the components outlined in the agreement. The functions with must be staffed by qualified persons in numbers appropriate to the CHC-MCO's size of Enrollment. The Department will determine has the right to make the final determination regarding whether or not the CHC-MCO is in compliancecompliance.‌ The CHC-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. The Similarly, the CHC-MCO may contract with a third party to perform one (1) or more of its these functions, subject to the subcontractor conditions described in Section XIIXIII, Subcontractual Relationships. The CHC-MCO is required to keep the Department informed at all times of the management individuals individual(s) whose duties include each of the responsibilities outlined in this section.section.‌

Other Administrative Components. The CHC-MCO must provide for each of the administrative functions listed below: . • A Quality Management/Quality Improvement Coordinator who is a Pennsylvania-licensed physician, RN, RN or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the The Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department’s EQR contractor. • A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the CHC-CHC- MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Participant care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement agreement requirements and coordinate with the BH-MCO to effectuate the requirements. • A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing Providers with prompt resolution of their problems or inquiries and appropriate education about participation in CHC and maintaining a sufficient Network. Individual Provider representatives will report directly to the Director of Network Management. • A UM Coordinator who is a Pennsylvania-licensed physician, RN or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the The Department may consider other advanced degrees relevant to UM in lieu of professional licensure. • A Director of Service Coordination who oversees all Service Coordination functions of the CHC plan and who shall have the qualifications of a Service Coordinator and a minimum of five (5) years of management/supervisory experience in the healthcare field. The Director of Service Coordination is responsible for all Service Coordination functions, whether the CHC-MCO provides all Service Coordinator functions in house or contracts with outside entities to meet Service Coordination requirements. • A Government Xxxxxxx who serves as the Department’s primary point of contact with the CHC-MCO for day-to-day management of contractual and operational issues. The CHC-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is notavailable. • A Participant Services Manager who oversees staff to coordinate communications with Participants and enables Participants to receive prompt resolution of their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the CHC-MCO and its Network Providers. There must be sufficient staff in CHC-MCO Provider Servicesservices, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers (e.g., e.g. HCBS Providers and Participant-Directed Services Providers) regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available CHC-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the CHC-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Participants throughout the Complaint, Grievance and DHS Fair Hearing processes. • A Claims Administrator who oversees staff to provide for the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement agreement requirements and the efficient management of the CHC-MCO. • A Contract Compliance Officer who monitors the CHC-MCO’s compliance with all the requirements of the Agreement. The All CHC-MCO staff must ensure all staff have appropriate training, education, experience, and orientation to fulfill the requirements of their position and maintain documentation of completionposition. The CHC-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The CHC-MCO’s staffing should represent the racial, ethnic, and cultural diversity of the Participants being served by CHC and comply with all requirements of Exhibit B, D Standard Terms and Conditions for Services. The Cultural Competency may be reflected by the CHC-MCO’s pursuit to: • Identify and value differences. • Acknowledge the interactive dynamics of cultural differences. • Continually expand cultural knowledge and resources with regard to the populations served. • Recruit racial and ethnic minority staff in proportion to the populations served. • Collaborate with the community regarding service provisions and delivery. • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The CHC-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement and include in its organizational structure the components outlined in this the Agreement. The CHC-MCO must staff these functions with qualified persons in numbers appropriate to the CHC-MCO's size of Enrollment. The Department will determine whether or not the CHC-MCO is in compliance. The CHC-MCO may contract with a third party to perform one (1) or more of its functions, subject to the subcontractor conditions described in Section XII, Subcontractual Relationships. The CHC-MCO is required to keep the Department informed at all times of the management individuals whose duties include each of the responsibilities outlined in this section.

Other Administrative Components. The CHC-MCO must provide for each of the administrative functions listed below: • A Quality Management/Quality Improvement Coordinator who is a Pennsylvania-licensed physician, RN, or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department’s EQR contractor. • A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the CHC-MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Participant care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement requirements and coordinate with the BH-MCO to effectuate the requirements. • A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing Providers with prompt resolution of their problems or inquiries and appropriate education about participation in CHC and maintaining a sufficient Network. Individual Provider representatives will report directly to the Director of Network Management. • A UM Coordinator who is a Pennsylvania-licensed physician, RN or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to UM in lieu of professional licensure. • A Director of Service Coordination who oversees all Service Coordination functions of the CHC plan and who shall have the qualifications of a Service Coordinator and a minimum of five (5) years of management/supervisory experience in the healthcare field. The Director of Service Coordination is responsible for all Service Coordination functions, whether the CHC-MCO provides all Service Coordinator functions in house or contracts with outside entities to meet Service Coordination requirements. • A Government Xxxxxxx Liaison who serves as the Department’s primary point of contact with the CHC-MCO for day-to-day management of contractual and operational issues. The CHC-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is notavailable. • A Participant Services Manager who oversees staff to coordinate communications with Participants and enables Participants to receive prompt resolution of their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the CHC-MCO and its Network Providers. There must be sufficient staff in CHC-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers (e.g., HCBS Providers and Participant-Directed Services Providers) regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available CHC-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the CHC-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Participants throughout the Complaint, Grievance and DHS Fair Hearing processes. • A Claims Administrator who oversees staff to provide for the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the CHC-MCO. • A Contract Compliance Officer who monitors the CHC-MCO’s compliance with all the requirements of the Agreement. The CHC-MCO must ensure all staff have appropriate training, education, experience, and orientation to fulfill the requirements of their position and maintain documentation of completion. The CHC-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The CHC-MCO’s staffing should represent the racial, ethnic, and cultural diversity of the Participants being served by CHC and comply with all requirements of Exhibit B, Standard Terms and Conditions for Services. The Cultural Competency may be reflected by the CHC-MCO’s pursuit to: • Identify and value differences. • Acknowledge the interactive dynamics of cultural differences. • Continually expand cultural knowledge and resources with regard to the populations served. • Recruit racial and ethnic minority staff in proportion to the populations served. • Collaborate with the community regarding service provisions and delivery. • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The CHC-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement and include in its organizational structure the components outlined in this Agreement. The CHC-MCO must staff these functions with qualified persons in numbers appropriate to the CHC-MCO's size of Enrollment. The Department will determine whether or not the CHC-MCO is in compliance. The CHC-MCO may contract with a third party to perform one (1) or more of its functions, subject to the subcontractor conditions described in Section XII, Subcontractual Relationships. The CHC-MCO is required to keep the Department informed at all times of the management individuals whose duties include each of the responsibilities outlined in this section.

Other Administrative Components. The CHC-MCO must provide for each of the administrative functions listed below: •  A Quality Management/Quality Improvement Coordinator who is a Pennsylvania-licensed physician, RN, or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department’s EQR contractor. •  A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the CHC-MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Participant care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement requirements and coordinate with the BH-MCO to effectuate the requirements. •  A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing Providers with prompt resolution of their problems or inquiries and appropriate education about participation in CHC and maintaining a sufficient Network. Individual Provider representatives will report directly to the Director of Network Management. •  A UM Coordinator who is a Pennsylvania-licensed physician, RN or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to UM in lieu of professional licensure. •  A Director of Service Coordination who oversees all Service Coordination functions of the CHC plan and who shall have the qualifications of a Service Coordinator and a minimum of five (5) years of management/supervisory experience in the healthcare field. The Director of Service Coordination is responsible for all Service Coordination functions, whether the CHC-MCO provides all Service Coordinator functions in house or contracts with outside entities to meet Service Coordination requirements. •  A Government Xxxxxxx who serves as the Department’s primary point of contact with the CHC-MCO for day-to-day management of contractual and operational issues. The CHC-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is notavailable. •  A Participant Services Manager who oversees staff to coordinate communications with Participants and enables Participants to receive prompt resolution of their issues, problems or inquiries. •  A Provider Services Manager who oversees staff to coordinate communications between the CHC-MCO and its Network Providers. There must be sufficient staff in CHC-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies. •  A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers (e.g., HCBS Providers and Participant-Directed Services Providers) regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available CHC-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the CHC-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. •  A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Participants throughout the Complaint, Grievance and DHS Fair Hearing processes. •  A Claims Administrator who oversees staff to provide for the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the CHC-MCO. • A Contract Compliance Officer who monitors the CHC-MCO’s compliance with all the requirements of the Agreement. The CHC-MCO must ensure all staff have appropriate training, education, experience, and orientation to fulfill the requirements of their position and maintain documentation of completion. The CHC-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The CHC-MCO’s staffing should represent the racial, ethnic, and cultural diversity of the Participants being served by CHC and comply with all requirements of Exhibit B, Standard Terms and Conditions for Services. The Cultural Competency may be reflected by the CHC-MCO’s pursuit to: • Identify and value differences. • Acknowledge the interactive dynamics of cultural differences. • Continually expand cultural knowledge and resources with regard to the populations served. • Recruit racial and ethnic minority staff in proportion to the populations served. • Collaborate with the community regarding service provisions and delivery. • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The CHC-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement and include in its organizational structure the components outlined in this Agreement. The CHC-MCO must staff these functions with qualified persons in numbers appropriate to the CHC-MCO's size of Enrollment. The Department will determine whether or not the CHC-MCO is in compliance. The CHC-MCO may contract with a third party to perform one (1) or more of its functions, subject to the subcontractor conditions described in Section XII, Subcontractual Relationships. The CHC-MCO is required to keep the Department informed at all times of the management individuals whose duties include each of the responsibilities outlined in this section.

Other Administrative Components. ‌ The CHC-MCO must provide for each of the administrative functions listed below: •  A Quality Management/Quality Improvement Coordinator who is a Pennsylvania-licensed physician, RN, or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department’s EQR contractor. •  A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the CHC-MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Participant care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement requirements and coordinate with the BH-MCO to effectuate the requirements. •  A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing Providers with prompt resolution of their problems or inquiries and appropriate education about participation in CHC and maintaining a sufficient Network. Individual Provider representatives will report directly to the Director of Network Management. •  A UM Coordinator who is a Pennsylvania-licensed physician, RN or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to UM in lieu of professional licensureprofessionallicensure. • A Director of Service Coordination who oversees all Service Coordination functions of the CHC plan and who shall have the qualifications of a Service Coordinator and a minimum of five (5) years of management/supervisory experience in the healthcare field. The Director of Service Coordination is responsible for all Service Coordination functions, whether the CHC-MCO provides all Service Coordinator functions in house or contracts with outside entities to meet Service Coordination requirements. •  A Government Xxxxxxx who serves as the Department’s primary point of contact with the CHC-MCO for day-to-day management of contractual and operational issues. The CHC-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is notavailable. •  A Participant Services Manager who oversees staff to coordinate communications with Participants and enables Participants to receive prompt resolution of their issues, problems or inquiries. •  A Provider Services Manager who oversees staff to coordinate communications between the CHC-MCO and its Network Providers. There must be sufficient staff in CHC-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies. •  A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers (e.g., HCBS Providers and Participant-Directed Services Providers) regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available CHC-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the CHC-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. •  A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Participants throughout the Complaint, Grievance and DHS Fair Hearing processesHearingprocesses. •  A Claims Administrator who oversees staff to provide for the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the CHC-MCO. • A Contract Compliance Officer who monitors the CHC-MCO’s compliance with all the requirements of the Agreement. The CHC-MCO must ensure all staff have appropriate training, education, experience, and orientation to fulfill the requirements of their position and maintain documentation of completion. The CHC-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The CHC-MCO’s staffing should represent the racial, ethnic, and cultural diversity of the Participants being served by CHC and comply with all requirements of Exhibit B, Standard Terms and Conditions for Services. The Cultural Competency may be reflected by the CHC-MCO’s pursuit to: • Identify and value differences. • Acknowledge the interactive dynamics of cultural differences. • Continually expand cultural knowledge and resources with regard to the populations served. • Recruit racial and ethnic minority staff in proportion to the populations served. • Collaborate with the community regarding service provisions and delivery. • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The CHC-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement and include in its organizational structure the components outlined in this Agreement. The CHC-MCO must staff these functions with qualified persons in numbers appropriate to the CHC-MCO's size of Enrollment. The Department will determine whether or not the CHC-MCO is in compliance. The CHC-MCO may contract with a third party to perform one (1) or more of its functions, subject to the subcontractor conditions described in Section XII, Subcontractual Relationships. The CHC-MCO is required to keep the Department informed at all times of the management individuals whose duties include each of the responsibilities outlined in this section.

Other Administrative Components. The CHC-MCO must provide for each of the administrative functions listed below: • .  A Quality Management/Quality Improvement Coordinator who is a Pennsylvania-licensed physician, RN, RN or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the The Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department’s EQR contractor. •  A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the CHC-CHC- MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Participant care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement agreement requirements and coordinate with the BH-MCO to effectuate the requirements. •  A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing Providers with prompt resolution of their problems or inquiries and appropriate education about participation in CHC and maintaining a sufficient Network. Individual Provider representatives will report directly to the Director of Network Management. •  A UM Coordinator who is a Pennsylvania-licensed physician, RN or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the The Department may consider other advanced degrees relevant to UM in lieu of professional licensureprofessionallicensure. • A Director of Service Coordination who oversees all Service Coordination functions of the CHC plan and who shall have the qualifications of a Service Coordinator and a minimum of five (5) years of management/supervisory experience in the healthcare field. The Director of Service Coordination is responsible for all Service Coordination functions, whether the CHC-MCO provides all Service Coordinator functions in house or contracts with outside entities to meet Service Coordination requirements. •  A Government Xxxxxxx Liaison who serves as the Department’s primary point of contact with the CHC-MCO for day-to-day management of contractual and operational issues. The CHC-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is notavailable. •  A Participant Services Manager who oversees staff to coordinate communications with Participants and enables Participants to receive prompt resolution of their issues, problems or inquiries. •  A Provider Services Manager who oversees staff to coordinate communications between the CHC-MCO and its Network Providers. There must be sufficient staff in CHC-MCO Provider Servicesservices, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies. •  A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers (e.g., e.g. HCBS Providers and Participant-Directed Services Providers) regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available CHC-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the CHC-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. •  A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Participants throughout the Complaint, Grievance and DHS Fair Hearing processesHearingprocesses. •  A Claims Administrator who oversees staff to provide for the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement agreement requirements and the efficient management of the CHC-MCO. • A Contract Compliance Officer who monitors the CHC-MCO’s compliance with all the requirements of the Agreement. The CHC-MCO must ensure all staff have appropriate training, education, experience, and orientation to fulfill the requirements of their position and maintain documentation of completion. The CHC-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The CHC-MCO’s staffing should represent the racial, ethnic, and cultural diversity of the Participants being served by CHC and comply with all requirements of Exhibit B, Standard Terms and Conditions for Services. The Cultural Competency may be reflected by the CHC-MCO’s pursuit to: • Identify and value differences. • Acknowledge the interactive dynamics of cultural differences. • Continually expand cultural knowledge and resources with regard to the populations served. • Recruit racial and ethnic minority staff in proportion to the populations served. • Collaborate with the community regarding service provisions and delivery. • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The CHC-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement and include in its organizational structure the components outlined in this Agreement. The CHC-MCO must staff these functions with qualified persons in numbers appropriate to the CHC-MCO's size of Enrollment. The Department will determine whether or not the CHC-MCO is in compliance. The CHC-MCO may contract with a third party to perform one (1) or more of its functions, subject to the subcontractor conditions described in Section XII, Subcontractual Relationships. The CHC-MCO is required to keep the Department informed at all times of the management individuals whose duties include each of the responsibilities outlined in this section.

Other Administrative Components. The CHC-MCO must provide for each of the administrative functions listed below: • .  A Quality Management/Quality Improvement Coordinator who is a Pennsylvania-licensed physician, RN, RN or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the The Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department’s EQR contractor. •  A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the CHC-CHC- MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Participant care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement agreement requirements and coordinate with the BH-MCO to effectuate the requirements. •  A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing Providers with prompt resolution of their problems or inquiries and appropriate education about participation in CHC and maintaining a sufficient Network. Individual Provider representatives will report directly to the Director of Network Management. •  A UM Coordinator who is a Pennsylvania-licensed physician, RN or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the The Department may consider other advanced degrees relevant to UM in lieu of professional licensure. •  A Director of Service Coordination who oversees all Service Coordination functions of the CHC plan and who shall have the qualifications of a Service Coordinator and a minimum of five (5) years of management/supervisory experience in the healthcare field. The Director of Service Coordination is responsible for all Service Coordination functions, whether the CHC-MCO provides all Service Coordinator functions in house or contracts with outside entities to meet Service Coordination requirements. •  A Government Xxxxxxx Liaison who serves as the Department’s primary point of contact with the CHC-MCO for day-to-day management of contractual and operational issues. The CHC-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is notavailable. •  A Participant Services Manager who oversees staff to coordinate communications with Participants and enables Participants to receive prompt resolution of their issues, problems or inquiries. •  A Provider Services Manager who oversees staff to coordinate communications between the CHC-MCO and its Network Providers. There must be sufficient staff in CHC-MCO Provider Servicesservices, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies. •  A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers (e.g., e.g. HCBS Providers and Participant-Directed Services Providers) regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available CHC-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the CHC-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. •  A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Participants throughout the Complaint, Grievance and DHS Fair Hearing processes. •  A Claims Administrator who oversees staff to provide for the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement agreement requirements and the efficient management of the CHC-MCO. • A Contract Compliance Officer who monitors the CHC-MCO’s compliance with all the requirements of the Agreement. The CHC-MCO must ensure all staff have appropriate training, education, experience, and orientation to fulfill the requirements of their position and maintain documentation of completion. The CHC-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The CHC-MCO’s staffing should represent the racial, ethnic, and cultural diversity of the Participants being served by CHC and comply with all requirements of Exhibit B, Standard Terms and Conditions for Services. The Cultural Competency may be reflected by the CHC-MCO’s pursuit to: • Identify and value differences. • Acknowledge the interactive dynamics of cultural differences. • Continually expand cultural knowledge and resources with regard to the populations served. • Recruit racial and ethnic minority staff in proportion to the populations served. • Collaborate with the community regarding service provisions and delivery. • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The CHC-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement and include in its organizational structure the components outlined in this Agreement. The CHC-MCO must staff these functions with qualified persons in numbers appropriate to the CHC-MCO's size of Enrollment. The Department will determine whether or not the CHC-MCO is in compliance. The CHC-MCO may contract with a third party to perform one (1) or more of its functions, subject to the subcontractor conditions described in Section XII, Subcontractual Relationships. The CHC-MCO is required to keep the Department informed at all times of the management individuals whose duties include each of the responsibilities outlined in this section.

Other Administrative Components. The CHC-MCO must provide for each of the administrative functions listed below: . • A Quality Management/Quality Improvement Coordinator who is a Pennsylvania-licensed physician, RN, RN or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the The Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department’s EQR contractor. • A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the CHC-CHC- MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Participant care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement agreement requirements and coordinate with the BH-MCO to effectuate the requirements. • A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing Providers with prompt resolution of their problems or inquiries and appropriate education about participation in CHC and maintaining a sufficient Network. Individual Provider representatives will report directly to the Director of Network Management. • A UM Coordinator who is a Pennsylvania-licensed physician, RN or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the The Department may consider other advanced degrees relevant to UM in lieu of professional licensureprofessionallicensure. • A Director of Service Coordination who oversees all Service Coordination functions of the CHC plan and who shall have the qualifications of a Service Coordinator and a minimum of five (5) years of management/supervisory experience in the healthcare field. The Director of Service Coordination is responsible for all Service Coordination functions, whether the CHC-MCO provides all Service Coordinator functions in house or contracts with outside entities to meet Service Coordination requirements. • A Government Xxxxxxx who serves as the Department’s primary point of contact with the CHC-MCO for day-to-day management of contractual and operational issues. The CHC-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is notavailable. • A Participant Services Manager who oversees staff to coordinate communications with Participants and enables Participants to receive prompt resolution of their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the CHC-MCO and its Network Providers. There must be sufficient staff in CHC-MCO Provider Servicesservices, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers (e.g., e.g. HCBS Providers and Participant-Directed Services Providers) regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available CHC-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the CHC-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Participants throughout the Complaint, Grievance and DHS Fair Hearing processesHearingprocesses. • A Claims Administrator who oversees staff to provide for the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement agreement requirements and the efficient management of the CHC-MCO. • A Contract Compliance Officer who monitors the CHC-MCO’s compliance with all the requirements of the Agreement. The All CHC-MCO staff must ensure all staff have appropriate training, education, experience, and orientation to fulfill the requirements of their position and maintain documentation of completionposition. The CHC-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The CHC-MCO’s staffing should represent the racial, ethnic, and cultural diversity of the Participants being served by CHC and comply with all requirements of Exhibit B, D Standard Terms and Conditions for Services. The Cultural Competency may be reflected by the CHC-MCO’s pursuit to: • Identify and value differences. • Acknowledge the interactive dynamics of cultural differencesculturaldifferences. • Continually expand cultural knowledge and resources with regard to the populations served. • Recruit racial and ethnic minority staff in proportion to the populations served. • Collaborate with the community regarding service provisions and delivery. • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The CHC-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement and include in its organizational structure the components outlined in this the Agreement. The CHC-MCO must staff these functions with qualified persons in numbers appropriate to the CHC-MCO's size of Enrollment. The Department will determine whether or not the CHC-MCO is in compliance. The CHC-MCO may contract with a third party to perform one (1) or more of its functions, subject to the subcontractor conditions described in Section XII, Subcontractual Relationships. The CHC-MCO is required to keep the Department informed at all times of the management individuals whose duties include each of the responsibilities outlined in this section.

Other Administrative Components. ‌ The CHC-MCO must provide for each of the administrative functions listed below: • A Quality Management/Quality Improvement Coordinator who is a Pennsylvania-licensed physician, RN, or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department’s EQR contractor. • A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the CHC-MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Participant care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement requirements and coordinate with the BH-MCO to effectuate the requirements. • A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing Providers with prompt resolution of their problems or inquiries and appropriate education about participation in CHC and maintaining a sufficient Network. Individual Provider representatives will report directly to the Director of Network Management. • A UM Coordinator who is a Pennsylvania-licensed physician, RN or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to UM in lieu of professional licensureprofessionallicensure. • A Director of Service Coordination who oversees all Service Coordination functions of the CHC plan and who shall have the qualifications of a Service Coordinator and a minimum of five (5) years of management/supervisory experience in the healthcare field. The Director of Service Coordination is responsible for all Service Coordination functions, whether the CHC-MCO provides all Service Coordinator functions in house or contracts with outside entities to meet Service Coordination requirements. • A Government Xxxxxxx who serves as the Department’s primary point of contact with the CHC-MCO for day-to-day management of contractual and operational issues. The CHC-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is notavailable. • A Participant Services Manager who oversees staff to coordinate communications with Participants and enables Participants to receive prompt resolution of their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the CHC-MCO and its Network Providers. There must be sufficient staff in CHC-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers (e.g., HCBS Providers and Participant-Directed Services Providers) regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available CHC-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the CHC-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Complaint, Grievance and DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Participants throughout the Complaint, Grievance and DHS Fair Hearing processesHearingprocesses. • A Claims Administrator who oversees staff to provide for the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the CHC-MCO. • A Contract Compliance Officer who monitors the CHC-MCO’s compliance with all the requirements of the Agreement. The All CHC-MCO staff must ensure all staff have appropriate training, education, experience, and orientation to fulfill the requirements of their position and maintain documentation of completionposition. The CHC-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The CHC-MCO’s staffing should represent the racial, ethnic, and cultural diversity of the Participants being served by CHC and comply with all requirements of Exhibit B, Standard Terms and Conditions for Services. The Cultural Competency may be reflected by the CHC-MCO’s pursuit to: • Identify and value differences. • Acknowledge the interactive dynamics of cultural differencesculturaldifferences. • Continually expand cultural knowledge and resources with regard to the populations served. • Recruit racial and ethnic minority staff in proportion to the populations served. • Collaborate with the community regarding service provisions and delivery. • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The CHC-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement and include in its organizational structure the components outlined in this Agreement. The CHC-MCO must staff these functions with qualified persons in numbers appropriate to the CHC-MCO's size of Enrollment. The Department will determine whether or not the CHC-MCO is in compliance. The CHC-MCO may contract with a third party to perform one (1) or more of its functions, subject to the subcontractor conditions described in Section XII, Subcontractual Relationships. The CHC-MCO is required to keep the Department informed at all times of the management individuals whose duties include each of the responsibilities outlined in this section.