Common use of Specialty Care Centers Clause in Contracts

Specialty Care Centers. Section 16 Quality Assurance 16.1 Internal Quality Assurance Program 16.2 Standards of Care Section 17 Monitoring and Evaluation 17.1 Right To Monitor Contractor Performance 17.2 Cooperation During Monitoring And Evaluation 17.3 Cooperation During On-Site Reviews 17.4 Cooperation During Review of Services by External Review Agency TABLE OF CONTENTS October 1, 2004 TABLE OF CONTENTS FOR MODEL CONTRACT Section 18 Contractor Reporting Requirements 18.1 Time Frames for Report Submissions 18.2 SDOH Instructions for Report Submissions 18.3 Liquidated Damages 18.4 Notification of Changes in Report Due Dates, Requirements or Formats 18.5 Reporting Requirements a. Annual Financial Statements b. Quarterly Financial Statements c. Other Financial Reports d. Encounter Data e. Quality of Care Performance Measures f. Complaint Reports g. Fraud and Abuse Reporting Requirements h. Participating Provider Network Reports i. Appointment Availability/Twenty-Four Hour (24) Access and Availability Surveys j. Clinical Studies k. Independent Audits l. New Enrollee Health Screening Completion Report m. Additional Reports n. LDSS Specific Reports 18.6 Ownership and Related Information Disclosure 18.7 Revision of Certificate of Authority 18.8 Public Access to Reports 18.9 Professional Discipline 18.10 Certification Regarding Individuals Who Have Been Debarred or Suspended by Federal or State Government 18.11 Conflict of Interest Disclosure 18.12 Physician Incentive Plan Reporting

Specialty Care Centers. Section 16 Quality Assurance 16.1 Internal Quality Assurance Program 16.2 Standards of Care Section 17 Monitoring and Evaluation 17.1 Right To Monitor Contractor Performance 17.2 Cooperation During Monitoring And Evaluation 17.3 Cooperation During On-Site Reviews 17.4 Cooperation During Dating Review of Services by External Review Agency TABLE OF CONTENTS October 1, 2004 4 TABLE OF CONTENTS FOR MODEL CONTRACT Section 18 Contractor Reporting Requirements 18.1 Time Frames for Report Submissions 18.2 SDOH Instructions for Report Submissions 18.3 Liquidated Damages 18.4 Notification of Changes in Report Due Dates, Requirements or Formats 18.5 Reporting Requirements a. Annual Financial Statements b. Quarterly Financial Statements c. Other Financial Reports d. Encounter Data e. Quality of Care Performance Measures f. Complaint Reports g. Fraud and Abuse Reporting Requirements h. Participating Provider Network Reports i. Appointment Availability/Twenty-Four Hour (24) Access and Availability Surveys j. Clinical Studies k. Independent Audits l. 1. New Enrollee Health Screening Completion Report m. Additional Reports n. LDSS Specific Reports 18.6 Ownership and Related Information Disclosure 18.7 Revision of Certificate of Authority 18.8 Public Access to Reports 18.9 Professional Discipline 18.10 Certification Regarding Individuals Who Have Been Debarred or Suspended by Federal or State Government 18.11 Conflict of Interest Disclosure 18.12 Physician Incentive Plan Reporting

Specialty Care Centers. Section 16 Quality Assurance 16.1 Internal Quality Assurance Program 16.2 Standards of Care Section 17 Monitoring and Evaluation 17.1 Right To Monitor Contractor Performance 17.2 Cooperation During Monitoring And Evaluation 17.3 Cooperation During On-Site Reviews 17.4 Cooperation During Review of Services by External Review Agency TABLE OF CONTENTS October 1, 2004 4 TABLE OF CONTENTS FOR MODEL CONTRACT Section 18 Contractor Reporting Requirements 18.1 Time Frames for Report Submissions 18.2 SDOH Instructions for Report Submissions 18.3 Liquidated Damages 18.4 Notification of Changes in Report Due Dates, Requirements or Formats 18.5 Reporting Requirements a. Annual Financial Statements b. Quarterly Financial Statements c. Other Financial Reports d. Encounter Data e. Quality of Care Performance Measures f. Complaint Reports g. Fraud and Abuse Reporting Requirements h. Participating Provider Network Reports i. Appointment Availability/Twenty-Four Hour (24) Access and Availability Surveys j. Clinical Studies k. Independent Audits l. Audit 1. New Enrollee Health Screening Completion Report m. Additional Reports n. LDSS Specific Reports 18.6 Ownership and Related Information Disclosure 18.7 Revision of Certificate of Authority 18.8 Public Access to Reports 18.9 Professional Discipline 18.10 Certification Regarding Individuals Who Have Been Debarred or Suspended by Federal or State Government 18.11 Conflict of Interest Disclosure 18.12 Physician Incentive Plan Reporting

Specialty Care Centers. Section 16 Quality Assurance 16.1 Internal Quality Assurance Program 16.2 Standards of Care Section 17 Monitoring and Evaluation 17.1 Right To Monitor Contractor Performance 17.2 Cooperation During Monitoring And Evaluation 17.3 Cooperation During On-Site Reviews 17.4 Cooperation During Review of Services by External Review Agency TABLE OF CONTENTS October 1, 2004 4 TABLE OF CONTENTS FOR MODEL CONTRACT Section 18 Contractor Reporting Requirements 18.1 Time Frames for Report Submissions 18.2 SDOH Instructions for Report Submissions 18.3 Liquidated Damages 18.4 Notification of Changes in Report Due Dates, Requirements or Formats 18.5 Reporting Requirements a. Annual Financial Statements b. Quarterly Financial Statements c. Other Financial Reports d. Encounter Data e. Quality of Care Performance Measures f. Complaint Reports g. Fraud and Abuse Reporting Requirements h. Participating Provider Network Reports i. Appointment Availability/Twenty-Four Hour (24) Access and Availability Surveys j. Clinical Studies k. Independent Audits l. 1. New Enrollee Health Screening Completion Report m. Additional Reports n. LDSS Specific Reports 18.6 Ownership and Related Information Disclosure 18.7 Revision of Certificate of Authority 18.8 Public Access to Reports 18.9 Professional Discipline 18.10 Certification Regarding Individuals Who Have Been Debarred or Suspended by Federal or State Government 18.11 Conflict of Interest Disclosure 18.12 Physician Incentive Plan Reporting

Specialty Care Centers. Section 16 Quality Assurance 16.1 Internal Quality Assurance Program 16.2 Standards of Care Section 17 Monitoring and Evaluation 17.1 Right To Monitor Contractor Performance 17.2 Cooperation During Monitoring And Evaluation 17.3 Cooperation During On-Site Reviews 17.4 Cooperation During Review of Services by External Review Agency TABLE OF CONTENTS October 1, 2004 4 TABLE OF CONTENTS FOR MODEL CONTRACT Section 18 Contractor Reporting Requirements 18.1 Time Frames for Report Submissions 18.2 SDOH Instructions for Report Submissions 18.3 Liquidated Damages 18.4 Notification of Changes in Report Due Dates, Requirements or Formats 18.5 Reporting 21 Participating Providers 21.1 Network Requirements a. Annual Financial Statements Sufficient Number b. Quarterly Financial Statements Absence of Appropriate Network Provider c. Other Financial Reports Suspension of Enrollee Assignments to Providers d. Encounter Data Notice of Provider Termination 21.2 Credentialing a. Licensure b. Minimum Standards c. Credentialing/Recredentialing Process d. Application Procedure 21.3 SDOH Exclusion or Termination of Providers 21.4 Evaluation Information 21.5 Payment In Full 21.6 Choice/Assignment of PCPs 21.7 PCP Changes 21.8 Provider Status Changes 21.9 PCP Responsibilities 21.10 Member to Provider Ratios 21.11 Minimum Office Hours a. General Requirements b. Medical Residents 21.12 Primary Care Practitioners a. General Limitations b. Specialists and Sub-specialists as PCPs c. OB/GYN Providers as PCPs d. Certified Nurse Practitioners as PCPs e. Quality Registered Physician's Assistants as Physician Extenders 21.13 PCP Teams a. General Requirements b. Medical Residents 21.14 Hospitals a. Tertiary Services b. Emergency Services 21.15 Dental Networks 21.16 Presumptive Eligibility Providers 21.17 Mental Health and Chemical Dependence Services Providers 21.18 Laboratory Procedures 21.19 Federally Qualified Health Centers (FQHCs) 21.20 Provider Services Function Section 22 Subcontracts and Provider Agreements 22.1 Written Subcontracts 22.2 Permissible Subcontracts 22.3 Provision of Services Through Provider Agreements 22.4 Approvals TABLE OF CONTENTS October 1, 2004 6 TABLE OF CONTENTS FOR MODEL CONTRACT 22.5 Required Components 22.6 Timely Payment 22.7 Restrictions on Disclosure 22.8 Transfer of Liability 22.9 Termination of Health Care Performance Measures f. Complaint Reports g. Professional Agreements 22.10 Health Care Professional Hearings 22.11 Non-Renewal of Provider Agreements 22.12 Physician Incentive Plan Section 23 Fraud and Abuse Reporting Requirements h. Participating Provider Network Reports i. Appointment Availability/Twenty-Four Hour (24) Access and Availability Surveys j. Clinical Studies k. Independent Audits l. New Prevention Plan Section 24 Americans With Disabilities Act Compliance Plan Section 25 Fair Hearings 25.1 Enrollee Health Screening Completion Report m. Additional Reports n. LDSS Specific Reports 18.6 Ownership and Related Information Disclosure 18.7 Revision of Certificate of Authority 18.8 Public Access to Reports 18.9 Professional Discipline 18.10 Certification Regarding Individuals Who Have Been Debarred or Suspended by Federal or State Government 18.11 Conflict Fair Hearing Process 25.2 Enrollee Rights to a Fair Hearing 25.3 Contractor Notice to Enrollees 25.4 Aid Continuing 25.5 Responsibilities of Interest Disclosure 18.12 Physician Incentive Plan ReportingSDOH 25.6 Contractor's Obligations