(OHCA website) May 16, Re: Year VI Contract Amendment. Dear SoonerCare Choice Provider:

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1 (OHCA website) May 16, 2001 Re: Year VI Contract Amendment Dear SoonerCare Choice Provider: Your current Medicaid contract with the SoonerCare Choice Program of the Oklahoma Health Care Authority (OHCA) will expire June 30, This is the last year of the three-year contract, which began July In order to accommodate Legislative requests to structure the contract on a calendar year basis, this renewal amendment will be for a six (6) month period, July 1, 2001 through December 31, This correspondence is written to summarize the changes that will be in effect for the remainder of the contract. The Oklahoma Health Authority elects to renew all existing contracts currently in effect. In addition to the existing services provided under the current contract, the OHCA and the provider mutually agree to amend the contract by adding the provisions of this Amendment. This renewal amendment shall apply to the SoonerCare Choice Contract and the specific paragraphs included herein. Other parts of the contract, and its Amendments not mentioned in this Amendment are not affected. Please return by June 15, 2001 to avoid any delay in payment for services rendered after June 30, You will receive confirmation of acceptance of your renewal by the OHCA. If you have any questions, please contact your provider representative toll-free at (877) Thank you for your participation in the SoonerCare Choice Program. Sincerely, Nancy Austin SoonerCare Contractor Services Rebecca Pasternik-Ikard SoonerCare Director

2 SoonerCare Choice Year VI Amendment #2 This amendment applies to the SoonerCare Choice three-year provider contract which began July 1, The terms of the original contract are replaced by the specific articles below. Other parts of the contract, and its Amendments not mentioned in this Amendment are not affected. Article Definitions 1.1A Aged, Blind & Disabled (ABD) a category of Medicaid eligibility based upon age, medical diagnosis and/or disability status 42 U.S.C. 1396a(a)(10)(A)(I) and (f), excluding those persons dually-eligible for Medicaid and Medicare, currently institutionalized, in state or tribal court ordered custody or served through a Home and Community Based Waiver, such as the Advantage Waiver. 1.1H Contract Year VI Six months of State Fiscal Year 2002 (July 1, 2001 December 31, 2001) Article 2.2 Responsibilities and Services Provided 2.2C Contractor shall submit encounter claim forms for all services provided to SoonerCare Choice members using the HCFA Encounter claims shall be submitted within 45 days of the date of service. (UB92 and K Forms will no longer be used) 2.2F Contractor is not responsible for providing referrals for: obstetrical, vision for refraction, dental, behavioral health services, emergency room services, or family planning services for adolescents under the age of eighteen. Article 2.3 Access to Care 2.3B Provide medical services for all recipients who enroll with or are assigned to the Contractor. Contractor may not exclude recipients who have enrolled with or been assigned to the Contractor from treatment because they are new or have not previously been seen by the Contractor or have an outstanding balance, except when the contractor has dismissed the member prior to their SoonerCare enrollment. Article 2.6 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) 2.6B For these activities, the Authority shall pay an enhanced case management fee of $3.00 per member, per month as provided in Section C In addition, for the services rendered in 2.6(A) as above, the Authority shall pay an EPSDT bonus payment, as described in Section 4.5, when the contractor achieves a fifty percent (50%) or higher annual compliance rate for Contract Year VI with the appointments described in Section 2.6(A)(1) for Contract Year VI. 2.6E If a safety net provider delivers the screen under the conditions described below, the school-based clinic or local health department will receive payment for EPSDT screens based on the Oklahoma Medicaid fee schedule rate, and a deduction will be made from the Contractor s capitation payments in subsequent months, pursuant to Section The deduction will be made from the Contractor s capitation payments if the school-based or local health department clinic does all of the following: 1) Verifies that the child is not current on the screening portion of the EPSDT periodicity schedule; 2) Attempts to arrange an appointment on the child s behalf with his or her PCP/CM within the next three (3) weeks; 3) Obtains a referral from the Contractor and conducts the required screen itself within the next three (3) weeks should an appointment with the Contractor not be arranged within the next three (3) weeks, and 4) Furnishes the record and results of the screen to the child s PCP/CM within a reasonable time. Article 2.7 Administrative Responsibility 2.7B Contractor shall obtain proper consent and transfer a member s medical records free of charge, if requested, in the event the member moves or changes PCP/CMs. Page 1

3 Article 3.2 Changing PCP/CMs 3.2C For any change as described in subsections A and B of this section, the Contractor shall provide the full scope of health care for any member who has selected or been assigned to the Contractor until the Authority officially reassigns the member. The effective date of change shall be set so as to avoid the issue of provider abandonment. The Contractor shall not notify the member of a change until the Contractor has received notification from the Authority pursuant to Section 3.3(B). Article 4.5 EPSDT Bonus Payment 4.5A Has achieved a seventy percent (70%) for Year!V, forty-five percent (45%) for Year V, and fifty percent (50%) for Year VI or better compliance level for EPSDT screens for the six (6) months during the terms of this contract as reflected by the periodicity schedule in Section 2.6(A)(1). Compliance shall be verified by an on-site chart audit after review of the encounter data submitted to the Authority by the Contractor. 4.5F The Authority shall make this additional payment in a lump sum within one hundred fifty (150) days after the end of the contract year. Payment shall be made at the rate of one dollar ($1.00) for each ESPDT-eligible member in the Contractor s panel during Contract Year VI (6 months), when the Contractor achieves an appropriate compliance rate as specified above. For each percentage point of compliance above the contractually specified compliance rate, the rate shall be multiplied by the difference between the specified compliance rate and the provider s actual compliance rate not to exceed 100%. The provider s actual compliance rate will be based upon encounter data submitted to the Authority no later than February 15, The EPSDT bonus payment will not exceed 20% of the provider s Year VI capitation payment for SoonerCare Choice. Article 4.7 Rate Adjustments for Year VI For Contract Year VI (July 1, 2001 December 31, 2001), rates will be reevaluated using encounter data. Rates will be adjusted appropriately for utilization and medical inflation. Article 4.10 Safety Net EPSDT The capitation rates shown in Attachment C reflect the established EPSDT screening requirements, as found in Section 2.6 (A)(1). The cost of EPSDT services covered under this contract provided by a school-based clinic or local health department clinic, pursuant to the provision of Section 2.6(E), will be deducted from the Contractor s capitation payment based on the Oklahoma Medicaid fee schedule rate. In no case will the deduction exceed an amount equal to one month s capitation for that member. This deduction provision shall be in effect from the time of execution of this contract. Article Capitation for Urgent, Emergency and Primary Care Services 4.12A The capitation rate paid pursuant to Section 4.1 through 4.4 above is for all primary care services. 4.12B Emergency medical condition services are not part of the capitation rate provided for in Section 4.1 through 4.4 above. If the service can be provided within his/her scope of practice, the provider may provide the service and be reimbursed for the emergency service at the current Medicaid fee schedule, if provided in the emergency room. Article 4.14 ABD Members Bridge Payment 4.14D A final bridge payment will be made following the end of each contract year, based on previous or current capitation revenue. All clean encounter claims submitted by February 28, 2002 will be considered in the final contract year bridge payment. Page 2

4 Article 5.1 General Conditions The term of this contract is from 12:01 a.m, July 1, 2001 to 12:00 midnight, December 31, 2001 This contract shall be effective upon signing and the receipt, processing and acceptance by OHCA. Article 5.6 Notices All notices to the Authority in accordance with this contract shall be mailed to: SoonerCare Choice Program Oklahoma Health Care Authority P.O. Drawer Oklahoma City, OK Any notice to the Contractor shall be mailed to the address listed on the primary office location page. Page 3

5 ATTACHMENT A IMMUNIZATION/INJECTIONS Code Pneumoccoccal conjugate vaccine, polyvalent, for intramuscular use Code Tetanus toxoid absorbed, for intramuscular or jet injection use Code Deleted MICROBIOLOGY Code Culture, bacterial; Any other source except urine, blood or stool with isolation and presumptive identification of isolates Code Culture, presumptive, pathogenic organisms, screening only Pursuant to Section 5.8 of the Contract, this Amendment and Attestation must be signed and mailed back to our office for the renewal to be valid for the remainder of the contracting period. Return these documents to: SoonerCare Choice Program Oklahoma Health Care Authority P.O. Drawer Oklahoma City, OK Page 4

6 SoonerCare Choice Year VI Amendment Attestation I,, hereby attest that: (Print name here) 1. All of my professional license(s) are current and in good standing. Y N 2. My malpractice insurance is at or above the level required in this contract and is currently in effect, with all premiums paid. Y N 3. I have a current and valid registration with the Oklahoma Bureau of Narcotics and Dangerous Drugs. Y N 4. I have a current and valid license with the Drug Enforcement Administration. Y N 5. I have a current Medicaid Fee-for-Service Contract. Y N Provider Signature STATE OF ) ) ss. COUNTY OF ) Before me, the undersigned, a Notary Public in and for said County and State on this day of, 2001, personally appeared to me known to be the identical person who executed the within and foregoing instrument and acknowledged to me that he/she executed the same as his/her free and voluntary act and deed for the uses and purposes therein set forth. Given under my hand and seal the day and year last above written. My Commission Expires Notary Public (SEAL) SoonerCare Choice Year VI Amendment Signatures Provider Signature Date Choice Provider # Print Name Here Choice Provider # Supervising Physician Signature Date (for Nurse Practitioner or Physician Assistant only) Fee for Service Provider # Printed Name Contact Person: Phone Number (Print Name) Page 5

7 ATTACHMENT A Medicaid covered services not listed in the capitated benefit section will be reimbursed at the current Medicaid fee-for-service rate subject to all current benefit limitations and prior authorization guidelines. PCP/CM Primary Care Capitated Services OFFICE VISIT - NEW PATIENT Office and other outpatient medical service, new patient; brief service Office and other outpatient medical service, new patient; limited service Office and other outpatient medical service, new patient; intermediate service Office and other outpatient medical service, new p atient; extended service Office and other outpatient medical service, new patient; comprehensive service OFFICE VISIT - ESTABLISHED PATIENT Office and other outpatient medical service, established patient; minimal service Office and other outpatient medical service, established patient; brief service Office and other outpatient medical service, established patient; limited service Office and other outpatient medical service, established patient ; intermediate service Office and other outpatient medical service, established patient; extended service NEW PATIENT - PREVENTIVE MEDICINE Office and other outpatient medical service, initial preventive medicine evaluation and management, infant early childhood, age late childhood, age adolescent, age years years years and over ESTABLISHED PATIENT - PREVENTIVE MEDICINE Periodic preventive medicine re-evaluation and management of an individual, infant early childhood, age late childhood, age adolescent, age years years years and over Code W3003 Description Administration of injections (other than chemotherapy) EPSDT

8 Attachment A Page 2 THERAPEUTIC OR DIAGNOSTIC INJECTIONS Therapeutic or diagnostic injection (specify material injected); subcutaneous or intramuscular Intramuscular injection of antibiotic (specify) IMMUNIZATIONS/INJECTIONS Immunization administration fee (this code is used if vaccine is obtained through the Vaccines for Children Program) Immunization administration fee (this code is used if vaccine is obtained through the Vaccines for Children Program) Hepatitis A vaccine, adult dosage, for intramuscular use Hepatitis A vaccine, pediatric/adolescent dosage 2 dose schedule, for intramuscular use Hepatitis A vaccine, pediatric/adolescent dosage 3 dose schedule, for intramuscular use Hemophilus influenza b vaccine (Hib) HbOC conjugate (4 dose schedule), for intramuscular use Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use Hemophilus influenza b vaccine (Hib), PRP conjugate (3 dose schedule), for intramuscular use Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use Influenza virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use Influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use Influenza virus vaccine, whole virus, for intramuscular or jet injection use Influenza virus vaccine, live, for intranasal use Pneumoccoccal conjugate vaccine, polyvalent, for intramuscular use Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for intramuscular use Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use Diphtheria and tetanus toxoids (DT) absorbed for pediatric use, for intramuscular use Tetanus toxoid absorbed, for intramuscular or jet injection use Mumps virus vaccine, live, for subcutaneous or jet injection use Measles virus vaccine, live, for subcutaneous or jet injection use Rubella virus vaccine, live, for subcutaneous or jet injection use Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous or jet injection use Measles and rubella virus vaccine, live, for subcutaneous or jet injection use Rubella and mumps virus vaccine, live, for subcutaneous use Measles, mumps, rubella and varicella vaccine (MMRV), live for subcutaneous use Poliovirus vaccine, (any types) (OPV), live, for oral use Poliovirus vaccine, inactivated, (IPV), for subcutaneous use Varicella virus, vaccine, live, for subcut aneous use Tetanus and diphtheria toxoids absorbed for adult use (Td), for intramuscular or jet injection Diphtheria toxoid, for intramuscular use Diphtheria, tetanus and pertussis (DTP) and Hemophilus influenza B (HIB) vaccine Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTaP-Hib), for intramuscular use Pneumococcal polysaccharide vaccine, 23-valent, adult dosage, for subcutaneous or intramuscular use Hepatitis B vaccine, pediatric or pediatric/adolescent dosage, for intramuscular use Hepatitis B vaccine, adolescent/high risk infant dosage, for intramuscular use Hepatitis B vaccine, adult dosage, for intramuscular use Hepatitis B vaccine, dialysis or immunosuppressed patient dosage, for intramuscular use Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use Code Description IMMUNOLOGY Immunoassay for infectious agent antibody, quantitative, not elsewhere specified Immunoassay for infectious agent antibody, quantitative or semi-quantitative, single step method (e.g., reagent strip) Particle agglutination; screen, each antibody Skin test; candida Tuberculosis, intradermal Tuberculosis, tine test

9 Attachment A Page 3 URINALYSIS Urinalysis by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrate, ph, protein, specific gravity, urobilinogen, any number of these constituents; with microscopy Without microscopy, non-automated Urine pregnancy test CHEMISTRY Basic metabolic panel: This panel must include the following; Carbon Dioxide, Chloride, Creatinine, Glucose, Potassium, Sodium, and Urea Nitrogen Bilirubin; total Blood, occult, feces screening, 1-3 simultaneous determinations Glucose, quantitative HEMATOLOGY AND COAGULATION Blood count, manual differential WBC count (includes RBC morphology and platelet estimation) Spun microhematocrit Other than spun hematocrit Hemogram, automated (RBC, WBC, Hgb, Hct and indices only) Hemogram, automated, and manual differential WBC count (CBC) Hemogram and platelet count, automated, and manual differential WBC count (CBC) Hemogram and platelet count, automated, and automated partial differential WBC count (CBC) Hemogram and platelet count, automated, and automated complete differential WBC count (CBC) Hemogram and platelet count, automated Blood count, hemogram, manual, complete CBC (RBC, WBC, Hgb, Hct, differential and indices) White blood cell (WBC) MICROBIOLOGY Culture, bacterial; any other source except urine, blood or stool, with isolation and presumptive identification of isolates Culture, presumptive, pathogenic organisms, screening only Culture, bacterial, urine, quantitative, colony count ANATOMIC PATHOLOGY Cytopathology, smears, cervical or vaginal, up to three smears; screening by technician under physician supervision (obtaining the smear); pathologist reading is not within the capitated service package and will be paid separately fee-for-service. MOLECULAR DIAGNOSTICS Gonadotropin, chronic (hcg); quantitative Qualitative

10 Attachment A Page 4 RADIOLOGY Code Description (Over-reads which are medically necessary are not within the capitated service package and will be paid separately fee-for-service.) Radiologic examination, chest; single view, frontal Radiologic examination, chest, 2 views, frontal and lateral Humerus, minimum of two views Radiologic examination, forearm, anteroposterior and lateral views Radiologic examination, femur, anteriorposterior and lateral views Radiologic examination, tibia and fibula, anteroposterior and lateral views Radiologic examination, elbow, anteroposterior and lateral views Radiologic examination, wrist, anteroposterior and lateral views Radiologic examination, hand; two views Radiologic examination, knee; anteroposterior and lateral views Radiologic examination, ankle, anteroposterior and lateral views Radiologic examination, foot, anteroposterior and lateral views Alternative codes used to bill for the services listed above may be changed to codes listed in the benefit package. Additional payment will not be generated.

SoonerCare Fax Blast

SoonerCare Fax Blast February 15, 2008 Subject: EPSDT and 4 th DPT/DTaP Encounters Dear Provider: Please note the following: EPSDT All encounters for EPSDT for 2007 dates of service must be filed before