Attachment 6 - Method of Approach Volume 7 01.05.13 … · Attachment 6 Method of Approach ......

Attachment 6 Method of Approach

ARIZONA DEPARTMENT OF HEALTH SERVICES

SOLICITATION NO: ADHS13-00002257

1740 West Adams Street Phoenix, Arizona 85007

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Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.

17.9 Participation in Information Systems Work Groups/Committees When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:

Mercy Maricopa Integrated Care (MMIC) recognizes that integrating the delivery of behavioral

and physical health care requires the effective gathering, management and reporting of data. We

will work with all relevant stakeholders to develop an information systems program that

facilitates the exchange of data as information across system partners. MMIC’s non-profit

sponsors, Maricopa Integrated Health System (MIHS) and Mercy Care Plan (MCP), have

extensive experience working with the state, stakeholders and providers on information systems.

Through this experience, we have learned that working closely with the state, stakeholders and

providers during implementation/readiness review is critical to a successful program.

MMIC is committed to successful implementation of the integrated model and will dedicate the

necessary resources to make this a successful program, including working with all providers,

including behavioral health providers on adopting electronic health records and health

information exchanges. Additionally, we have the ability to leverage the considerable resources

available through our affiliated plans and Aetna, which affords us access to a vast pool of

expertise. Our affiliated plans and Aetna have extensive expertise in developing technical

initiatives for integrated models across the country.

MMIC’s non-profit sponsors, MIHS and MCP, have been collaborating with AHCCCS to

provide resources and technology in support of Arizona’s Health Information Exchange (HIE)

platform, and any future enhancements, assisting with the development of the state’s Health-e

project plan and e-prescribing initiatives, implementing all required data exchange interfaces,

and building upon existing EHR capabilities. For example, MCP recently collaborated with

AHCCCS to discuss implementation of the Arizona Exchange Care Coordination initiative.

Similarly, our affiliates continue to work together with multiple state agencies in the

development of HIT and related (e.g., Electronic Health Record (EHR)) technology. For

Offeror: Mercy Maricopa Integrated Care ADHS13-00002257

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example, Delaware Physicians Care, Inc., (DCPI) a MMIC affiliate, has been actively involved

in the development and deployment of a clinical information sharing utility as part of the

Delaware Health Information Network (DHIN) initiative for many years. Currently considered

by many as the most advanced utility for health information exchange in the nation, DHIN

provides electronic sharing of Electronic Medical Record (EMR) information among

participating health care providers including primary care, specialist, hospital and ancillary

providers.

17.9.1 Participation in AHCCCS Workgroups Including Technical Consortiums

MMIC will actively participate with stakeholders and system partners in the AHCCCS Technical

Consortium, previously the National Provider Identification (NPI) Consortium; the HIPAA 5010

Consortiums; AHCCCS 5010 834 Consortium; ICD-10 Consortiums; and electronic data

interface (EDI) committee meetings. Following contract award, and as part of our

implementation plan outlined in RFP Section 18.24.5, MMIC’s IT management team will reach

out to AHCCCS’ technical consortiums and schedule introductory meetings. Going forward, our

Information Systems Administrator will serve as the MMIC Representative for all IT-related

workgroups and committees.

MMIC intends to use this contract award as a key driver to address historical gaps in accuracy of

the assignment of the primary care providers as managed under AHCCCS. In order to fulfill the

state’s vision of the patient’s whole health, the ability to identify and maintain the patient’s

primary care provider within the AHCCCS enrollment is strategic to facilitate that care. MMIC

envisions AHCCCS will work with the AHCCCS plans to raise the importance of maintaining

that information and closely with HINAz on the proposed provider directory.



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17.9.2 Participation as a Data User in HinAZ

MMIC is committed to being an active participant as a data user in the Health Information

Network of Arizona (HINAz). Our partner organizations, Mercy Care Plan and Maricopa

Integrated Health Systems (MIHS), currently participate in AHCCCS work groups, including the

HINAz work group. The MIHS COO, Bill Vanaskie, is Chairman of the HINAz Board of

Directors, and MIHS has also participated in AMIE, the AHCCCS predecessor to HINAz.

MMIC will be committed to furthering HINAz’s goal of building the state’s largest non-profit

health information exchange system where authorized health care providers can safely access

electronic records anywhere, any time. We will contribute our Information Technology team’s

expertise to HINAz to develop an exchange that allows physicians to make appropriate, safe

decisions about care, even if they have never seen that patient before, to improve the access,

quality, and safety of health care while reducing the costs of care in Arizona. MMIC will

continue to collaborate and build towards enhancing access to timely information, including:

MMIC will work with HINAz and Behavioral Health Providers to determine the best strategy

towards integrating with HINAz, as currently HINAz does not permit Behavioral Health

information to be shared across the HINAz exchange.

MMIC will work with Arizona Strategic Enterprise Technology Office (ASET) to identify

opportunities to utilize other funding sources, similar to the State of Arizona Health

Information Exchange (AZHIE) Unconnected Providers’ grant program supporting Health

Information Exchange (HIE) planning and implementation for health care organizations and

healthcare providers who have not yet planned or implemented a HIE solution.

MMIC will engage Arizona Health-e Connection, a network of companies, organizations and

individuals dedicated to better health and wellness through advancing health IT and a health

information infrastructure for all of Arizona. We will work with Arizona Health-e



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Connection to advocate and advance secure and private health IT, and to create a health

information infrastructure for Arizona through a public-private partnership of all health care,

business and government stakeholders to bridge the gap of the behavioral health and primary

care services.

MMIC is committed to the successful implementation of the integrated model, and we will

dedicate the necessary resources to make this a successful program by working with all

providers, including behavioral health providers on adopting electronic health records and health

information exchanges.

17.10 Enrollment and Eligibility Data Exchange When responding, include

a. Offeror’s strategies for its Implementation Plan consistent with 18.24.5. b. Information to show capability of its Enrollment and Eligibility Data Exchange System (System) in

accordance with the following. Exhibit 14, Member History Test Document, includes redacted HIPAA-compliant 834 enrollment records for thirteen (13) members. This member information is a representation of the actual data Contractor is required to load and interpret in significant volume. Offerors should process the records in Exhibit 14 and create accurate enrollment histories for each member by submitting Attachment 6.4. Offerors should use the guidance provided in Exhibit 7, Client Information System (CIS) File Layouts and Specifications Manual, and IT Guidance Documents.

Offeror Response:

Mercy Maricopa Integrated Care’s (MMIC) sponsor, Mercy Care Plan (MCP), has been

successfully supporting enrollment and eligibility management processes in Arizona Medicaid

since 1986. MCP’s experience includes multi-program enrollment and eligibility including

AHCCCS Acute Care, Kids Care, ALTCS, DES DD, Medicare Advantage Special Needs Plan

(SNP) and Health Care Group. Each of these programs has unique eligibility requirements. We

have the experience and infrastructure to support all aspects of the RBHA enrollment and

eligibility process.



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Better Health Enterprise System Platform™ (BH-ESP) will support the required EDI

transactions and complies with all applicable HIPAA requirements, as well as the procedures,

policies, rules and statutes in effect during the term of our contract. Figure 1: BH-ESP accepts

and generates enrollment and eligibility transactions required to and from all stakeholders

involved in the process.

BH-ESP will process HIPAA-compliant transactions easily and efficiently, allowing MMIC to

accept information electronically from almost any HIPAA-compliant contractor or provider.

BH-ESP will invoke data transformation services that translate data to and from the full spectrum

of HIPAA transactions sets in a highly configurable, agile, and robust system environment.

Primarily, BH-ESP will utilize the following electronic transactions to support enrollment and

eligibility data exchange (including SMI status) for all clients, including Non-Title XIX/XXI

eligible members, as detailed in Table 1 below.

Table 1: Electronic Transactions Utilized Transaction Description

ANSI X12 834 Benefit Enrollment and Maintenance

ANSI X12 270 Eligibility, Coverage or Benefit Inquiry



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Transaction Description

ANSI X12 271 Eligibility, Coverage or Benefit Information/Response

BH-ESP also includes support and complies with ADHS/DBHS’ data processing and interface

requirements including:

Client Information System (CIS) File Layouts and Specifications Manual

ADHS/DBHS Operations and Procedures Manual

ADHS/DBHS Policy and Procedure Manual

ADHS/DBHS Covered Behavioral Health Services Guide

ADHS/DBHS Office of Grievances and Appeals Database Manual Docket Tracking

Application Users Guide

Demographic and Outcome Dataset User Guide (42 CFR 438.242(a))

MMIC will have dedicated considerable resources to develop the functionality and support to

keep pace with the changes in HIPAA requirements. We will engineer our systems to meet the

requirements of the current HIPAA Transactions and Code Sets regulations and the Client

Information System (CIS) File Layout and Specifications Manual. We will also be active at the

federal level to address future HIPAA mandates as they arise. We will follow the Strategic

National Implementation Project (SNIP) recommendations for testing created by the Workgroup

for Electronic Data Interchange (WEDI).

17.10.1 Accept and Utilize Electronic Client Eligibility/Enrollment Information

To support the management of client enrollment and eligibility information across RBHA

stakeholders, BH-ESP will facilitate data exchange and data sharing of Client

Eligibility/Enrollment Information utilizing the 834 CMS-Prescribed version standard formats



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for eligible members in conformance with the Client Information System (CIS) File Layouts and

Specifications Manual.

17.10.2 Require Subcontracted Providers to Collect Enrollment Information in the 834

CMS-Prescribed Version Standard Formats for Non-Title XIX/XXI Eligible Members

MMIC will share and require our subcontracted providers to share enrollment information in the

834 CMS-Prescribed version standard formats for Non-Title XIX/XXI-eligible members as well.

17.10.3 Submit Enrollment Information in the 834 CMS-Prescribed Version Standard

Formats for Non- Title XIX/XXI Eligible Members

MMIC will submit enrollment information in the 834 CMS-prescribed version standard formats

for Non- Title XIX/XXI eligible members to ADHS/DBHS. As described above, this will be our

standard and preferred protocol for all client enrollment transactions.

17.10.4 Share Information as Needed with AHCCCS/SSI-MAO to Assist in the Title

XIX/XXI Eligibility Determination

MMIC will also facilitate the Title XIX/XXI eligibility determination process with

AHCCCS/SSI-MAO by sharing through structured transaction protocol the appropriate

information, including the applicant’s screening information, behavioral health history and SMI

status, with AHCCCS/SSI-MAO.

Please see the Attachments tab of ProcureAZ for MMIC’s Member History Test files.



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17.11 Claims and Encounter Submission and Processing Requirements When responding, include:

a. Offeror’s strategies for its Implementation Plan consistent with 18.24.5. b. A detailed flowchart and narrative description of the claims/ encounters adjudication processes,

addressing both paper and electronic claims submissions that contain a description of the following:

1) The monitoring process for accurate and timely claim adjudication; 2) How deficiencies are identified and resolved; 3) Timeliness standards and cost avoidance/TPL activities; and 4) How claim inquiries are addressed and resolved.

c. A sample of the remittance advice (front and back) or a written narrative of the remittance advice. d. For encounters, describe the process to ensure the accuracy, timeliness, completeness is and

the remediation process when standards are not met.

Offeror Response:

Mercy Maricopa Integrated Care (MMIC) will subcontract management of all administrative

services to Schaller Anderson (Schaller), LLC, an Aetna company, with more than 25 years’

experience managing the care of the most medically vulnerable. Schaller owns and administers

Medicaid managed health care plans for more than one million members, and provides care

management services to hundreds of thousands of high-cost, high-need Medicaid members. It

utilizes a variety of delivery systems, including fully capitated health plans, complex care

management, and administrative service organizations. MMIC will use these innovative

approaches to achieve both successful health care results and maximum cost outcomes.

MMIC’s Chief Operating Officer (COO), Michel Fronske, will be responsible for and has

authority over Schaller’s claims performance. The COO will be supported by the Vice President

of Health Plan Operations (HPO), together they will oversee MMIC’s full compliance with all

applicable AHCCCS and federal requirements, maintaining processes that meet claims processing

timelines, maximize cost avoidance, and minimize claims recoupment.



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Our Vice President of Health Plan Operations and Claims Administrator, John Monte will

review, approve, date and sign all claims Policies and Procedures (P&Ps) annually to verify their

agreement with current practices and support continued compliance with applicable AHCCCS

standards and requirements.

Through Schaller, MMIC is confident we will be able to provide encounter accuracy and

implement corrective action plans to maintain high levels of accuracy.

MMIC’s Information Technology (IT) staff, under the direction of the Information Systems

Administrator, will review all strategies for implementing the Management Information System,

claims and encounter processing, and other systems that rely on data or data processing to

achieve full compliance with all contractual obligations. Key IT staff will coordinate our efforts

to collect, analyze, integrate and report data. They will utilize the following documents to assist

in implementation activities:

AHCCCS HIPAA Transaction Companion Guides & Trading Partner Agreements

AHCCCS Encounter Manual

AHCCCS Technical Interface Guidelines


Additionally, MMIC will comply with all data submission standards required by this Contract,

and accept ADHS/DBHS rejection of non-compliant submissions.



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17.11.1 ADHS/DBHS Claims and Encounter Submission Requirements

17.11.2 ADHS/DBS Claims and Encounter Submission Deadlines

17.11.3 Deadlines for Eligible Federal Drug Rebate Processing Pharmacy Encounter

Submissions

MMIC has subcontracted with Schaller Anderson, LLC (Schaller), LLC, an Aetna company, to

maintain a centralized, HIPAA-compliant claims processing and payment system capable of

processing, cost avoiding and paying claims in accordance with A.R.S. §§ 36-2903 and 2904 and

AHCCCS Rules R9-22 Article 7.

Schaller, as part of its management subcontracting agreement, will provide full claims

administration through a claims management organization. It will be led by a local Claims

Director. Centralizing claim processing functions at Schaller allows MMIC to take advantage of

economies of scale and quality efficiencies. Schaller's claim processing team adjudicates for

more than a million Medicaid lives.

MMIC's Chief Operating Officer (COO) has responsibility and authority over Schaller's claims

performance. During implementation, the COO will oversee the development of written policies

and along with the Information Systems Administrator and the Vice President of Health Plan

Operations will be accountable for our testing procedures so that our systems and processes are

in full compliance with all applicable AHCCCS and federal requirements, and maintain claims

processing timelines, maximize cost avoidance, and minimize claims recoupment. Our Vice

President of Health Plan Operations and Claims Director will review, approve, date and sign all

claims Policies and Procedures (P&Ps) annually to confirm their agreement with current

practices, and support continued compliance with applicable AHCCCS standards and

requirements.

The cornerstone of the claims adjudication process, QNXT™, was upgraded to version 4.8 as

recently as January 2012, and passed an independent post-migration audit. Future plans include



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additional upgrades in anticipation of approaching ICD-10 requirements. This HIPAA-

compliant, rules-based claims adjudication system has processed more than 1,214,023 claims for

our sponsor MCP’s Arizona Long Term Care System (ALTCS) line of business from January 1,

2012, through November 30, 2012.

Building on the QNXT™ experience in Arizona, MMIC will have the capacity to process

copious amounts of claims

data. The QNXT™ system is

so effective that, for the 10

months ending February 2011,

an average of 98.8 percent of

MCP’s claims were finalized

within 30 calendar days or less,

with 99.5 percent within 60

calendar days.

Using the Plan-Do-Study-Act (PDSA) protocols, Schaller will continue to make process

improvements that increase financial and payment accuracy. For example, during past calendar

years, system audit results for MCP have averaged 99.3 percent (financial) and 98.3 percent

(payment) accuracy rates.

Schaller's claim system runs on a high-speed Local Area Network (LAN) and Wide Area

Network (WAN) and cluster of servers with built in redundancy. This system and its

configuration provide all necessary computing power, redundancy and scalability to meet both

enrollment growth and increases in AHCCCS specifications or requirements. Schaller is able to

add servers to increase performances vertically, and they are designed to accept increases in

RAM and processing power to grow horizontally. That scalability allows the claims system to

The QNXT™ system is so effective that, for the 10 months ending February 2011, an average of 98.8 percent of MCP’s claims were finalized within 30 calendar days or less, with 99.5 percent within 60 calendar days.

Using the Plan-Do-Study-Act (PDSA) protocols, Schaller will continue to make process improvements that increase financial and payment accuracy. For example, during past calendar years, system audit results for MCP have averaged 99.3 percent (financial) and 98.3 percent (payment) accuracy rates.



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match any escalation in volume associated with enrollment growth while maintaining

responsiveness, up-time and performance. The Schaller system will enable MMIC to:

Submit claims and encounters to ADHS/DBHS or AHCCCS, as directed by ADHS/DBHS

and in conformance with the Client Information System (CIS) File Layouts and

Specifications Manual, ADHS/DBHS Office of Program Support Operations and Procedures

Manual, ADHS/DBHS Provider Manual, 6.2 Submitting Claims and Encounters to the

RBHA, the ADHS/DBHS Covered Behavioral Health Services Guide, and the ADHS/DBHS

Financial Reporting Guide for GSA 6

Submit claims and encounters to ADHS/DBHS or AHCCCS, as directed by ADHS/DBHS,

in conformance with the HIPAA Transaction Companion Guides & Trading Partner

Agreements, the AHCCCS Encounter Manual, no later than 210 days after the end of the

month in which the service was rendered, or the effective date of the enrollment with the

Contractor, whichever date is later

Submit pharmacy encounter data and other encounters involving services eligible for Federal

Drug Rebate processing no later than 30 days after the end of the quarter in which the

pharmaceutical item was dispensed.

Claims Adjudication

MMIC, through Schaller, will have the experienced to process medical and behavioral health,

and Medicare claims, and understands that all

three types will be included in the RBHA

contract. We will accommodate both electronic

and paper claims submission. However, we

prefer and actively encourage providers to take

advantage of our HIPAA-compliant electronic

transaction capabilities. They include electronic claims submission (EDI), Electronic Remittance

Advice (ERA) distribution, and Electronic Funds Transfer (EFT). In fact, for the rolling 12

For the rolling 12 months ending November 2012, an average of 75.7 percent of Schaller’s ALTCS claims were received through our HIPAA compliant Electronic Data Interchange (EDI) system.



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months ending November 2012, an average of 75.7 percent of Schaller’s ALTCS claims were

received through our HIPAA compliant Electronic Data Interchange (EDI) system. MMIC

claims processing will be able to support the needs of all of provider types that render services to

the RBHA population, such as paying claims for Home- and Community-Based Services

(HCBS) providers for ALTCS.

17.11.4 Requirement for Compliant Provider Claims and Encounter Submissions

MMIC will require providers to submit claims or encounters in conformance with the

ADHS/DBHS Provider Manual, 6.2 Submitting Claims and Encounters to the RBHA, the

ADHS/DBHS Office of Program Support Operations and Procedures Manual, the ADHS/DBHS

Covered Behavioral Health Services Guide, the ADHS/DBHS Financial Reporting Guide for

GSA 6, the Client Information System (CIS) File Layouts and Specifications Manual

requirements, in accordance with HIPAA for each covered service delivered to a member.

Claims received in a paper format will be scanned by Future Vision Technologies, a Schaller

vendor. They will then be loaded into the QNXT™ system for adjudication. Claims received

electronically via one of MMIC's clearinghouse partners will be loaded directly into the

QNXT™ system. Once the electronic files are loaded, the IT department will run a daily batch

process to auto adjudicate 75.5 percent (average contract year to date) of our ALTCS claims.

During that process, a series of CCI-compliant claims edits will be applied based on QNXT™,

ClaimCheck® and iHealth software applications. These applications consistently and uniformly

apply comprehensive edits to automatically pay, pend or deny each claim.

As an example, Figure 1 on the following page illustrates All Claims Received via EDI and All

Claims Auto-Adjudicated by Month.



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Figure 1: KIR #8 All Claims Received via EDI and All Claims Auto-Adjudicated by Month – ALL SAI

QNXT™ applies claims adjudication logic to reimburse non-participating providers at no more

than the established AHCCCS Fee-For-Service rate at the time the service was rendered, based

on the location of service. This is done by automatically applying AHCCCS' reimbursement

schedules and reference files, authorization requirements, provider configuration and processing

rules to the claim as part of the adjudication process. Claims that fail to auto adjudicate,

regardless of reason, are automatically pended for manual review. With the exception of those

that pend for medical or HCBS review, a Claims Analyst with appropriate experience,

knowledge and training, will perform the manual review and adjudicate the claim. The Claims

Analyst, using a comprehensive set of claim P&Ps, will analyze and resolve the edits in order to



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adjudicate the claim. The goal will be to resolve all clean claims pended for manual review

within 30 days.

Claims will pend for medical review because of outliers, facility authorization mismatch and

reconsiderations based on additional medical information. They will be pended for further

review to a medical management team under the direction of the Medical Management

Administrator. An RN, with appropriate training and expertise, will review the claim, applying

MMIC’s P&Ps and clinical practice guidelines or similar medical criteria, to determine final

adjudication status of the claim. The Deputy Medical Officer (DMO) or Medical Director

designee will be available to assist if necessary. Our goal will be to resolve all clean claims

pended for manual review within 30 calendar days.

Claims will pend for HCBS review because of mismatched HCBS authorizations, member share

of cost clarification and member room and board clarification. They will be pended to a

specialized HCBS unit, reporting to the Vice President of Health Plan Operations for further

review. An MMIC Claims Analyst, with appropriate training and experience in both case

management and claims adjudication, will apply our P&Ps to determine final status of the claim.

The goal will be to resolve all claims pended for manual review with 30 calendar days.

Claims are set to finalized status if they are auto adjudicated, or have had a manual intervention

that sets them to pay. MMIC will then conduct weekly check runs or make EFT payments to

providers, and send a remittance advice for all finalized claims. We will monitor internal claims

reports to make certain payment is within AHCCCS timeliness standards.

17.11.5 Compliance with All Timeliness, Accuracy and Omission of Data Requirements

MMIC will comply with all timeliness, accuracy and omission of data requirements for

processing encounters in conformance with the ADHS/DBHS Office of Program Support



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Operations and Procedures Manual, and be subject to financial sanction for non-compliance with

encounter or claim submission standards.

Coordination of Benefits (COB) and Third Party Liability (TPL)

MMIC's standard operating procedure will be to coordinate benefits with primary insurance or

recover payments from other liable parties before applying Medicaid as a source of payment. As

85 percent of ALTCS members are dually eligible, we will apply claims-specific edits to

maximize cost avoidance according to ACOM Medicare Cost Sharing policies.

We will identify potential COB opportunities through information received from AHCCCS;

Health Management Systems (HMS); internal staff, including Care Managers; members; claims,

and Explanation of Benefits (EOB). If we verify Other Insurance (OI), we will move to last

payer position and adjudicate the claim in accordance with our COB protocols.

When we receive a claim without an EOB attached, and the member's eligibility record identifies

OI, we will deny the claim. Our internal training department will provides training to all staff

with exposure to claims and encounters to identify and report COB and TPL opportunities.

Once OI is confirmed, we will update the member's eligibility record. If OI is retroactive, a

Claims Analyst will research the member's claims history, and any funds paid as primary are

slated for recoupment.

MMIC’s sponsor, Mercy Care Plan (MCP), operates a CMS Medicare Advantage Special Needs

Plan (SNP) called Mercy Care Advantage (MCA). For members who are dually eligible and

enrolled with both MMIC and MCA, we will auto adjudicate claims to apply first to the

Medicare benefit, and then apply the remainder to the Medicaid benefit.

We will refer MMIC members who may be eligible for Children's Rehabilitative Services (CRS)

and who also have private insurance or Medicare coverage to CRS for determination of



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eligibility for CRS Service. We will update the member benefits profile as necessary, and handle

care coordination and payment responsibility accordingly.

Our COB team, utilizing the AHCCCS protocols, will report verified OI that has not been

received via AHCCCS files to AHCCCS no later than 10 calendar days from the date of

discovery. In addition, we will notify AHCCCS of any known change in coverage, including

Medicare, via the appropriate technical interface.

For TPL, our standard operating procedure will be to "pay and chase". We will contract with

Recovery Management Services (RMS) to recover payment when applicable. We will route

claims received with indication of potential TPL opportunities, based on diagnosis codes, to

RMS for recovery. RMS will investigate and pursue recoveries, and return to MMIC any

remuneration from other payers or insurers.

We will contract with Health Management Systems (HMS) to recover payments MMIC makes

as primary when the member had OI for the dates of service. Recoveries that HMS pursues on

our behalf will be for claims payments that are older than a year. HMS will work directly with

the identified insurance carrier,

not the provider.

MMIC will submit, on a

quarterly basis, a summary of

our cost avoidance/recovery

activity as specified in the

AHCCCS Program Integrity Reporting Guide. MMIC will adopt our sponsor’s MCP, standard

operating procedures. In calendar year 2011, MCP successfully avoided $73,540,581 in

overpayments. A flowchart of TPL/COB process can be found as Figure 5 at the end of this

section.

MMIC will submit, on a quarterly basis, a summary of our cost avoidance/recovery activity as specified in the AHCCCS Program Integrity Reporting Guide.

MMIC will adopt our sponsor’s MCP, standard operating procedures. In calendar year 2011, MCP successfully avoided $73,540,581 in overpayments.



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Provider Claims Inquiries

MMIC’s staff, comprising our Network Development Administrator and 31 local Full Time

Equivalents (FTEs) including a Provider Services Director, two Provider Services Managers,

and a cadre of Provider Services Representatives (PSRs), will respond to provider inquiries and

complaints, as well as offer education to providers and their staffs. In addition, the Claims

Administration department will have 24 local FTEs including full-time Claims Inquiry and

Claims Research (CICR) Representatives to respond to provider questions, status inquiries and

payment issues via our claims inquiry line. It will be staffed from 8 a.m. to 5 p.m., Monday

through Friday (excluding holidays), and an automated telephone system will allow callers to

speak with a Representative or leave a detailed message regarding their inquiry.

QNXT™'s call tracking module maintains a record of any provider inquiry, request, or

complaint. We will research, resolve or respond to all reported issues within 10 business days,

with response timeliness and resolution monitored via call management tracking reports.

Whenever possible, reported issues will be resolved immediately. We will submit issues

requiring in-depth research and resolution to the Health Plan Operations department. Provider

Services personnel will also respond to inquiries and requests for claims review received via e-

mail, fax transmission or mail. Finally, providers will be able to access detailed information

through our secure HIPAA-compliant web portal. An illustration of our provider claim inquiry

process can be found as Figures 2-4 at the end of this section.

Please see the Attachments tab of ProcureAZ for a front and back sample of Mercy Maricopa

Integrated Care (MMIC)’s Remittance Advice.



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17.11.6 Development and Implementation of Policies and Procedures:

17.11.6.1 To process encounters accurately, timely and complete 17.11.6.2 For encounters to describe the services provided 17.11.6.3 To accurately adjudicate encounters in conformance with AHCCCS and ADHS/DBHS requirements 17.11.6.4 Comply with all state and federal requirements

MMIC will implement highly developed claims processing policies and procedures to make sure

we process encounters accurately, promptly and completely. Utilizing a proprietary encounter

system, we will make certain encounters describe the services provided, accurately adjudicate

encounters in conformance with AHCCCS and ADHS/DBHS requirements, and comply with all

state and federal requirements.

MMIC’s sponsor Mercy Care Plan (MCP)’s proprietary Encounter Management System (EMS)

will be used to provide for accurate, timely and complete submission of encounter data –

including all billed, paid and denied units and charges, as well as the National Provider Identifier

(NPI) – to AHCCCS in HIPAA compliant 837(I/P) format. EMS will receive and process

encounter data from behavioral health, vision, dialysis, transportation and lab providers as well.

Developed with the functionality to manage encounter data across the encounter submission

continuum – including preparation, review, verification, certification, submission and reporting,

it will consolidate required claims data from multiple sources (such as QNXT™ and our

Pharmacy Benefits Manager) for all services (including those in the prior period) for which

MMIC will incur a financial liability, as well as claims for services eligible for processing where

no financial liability was incurred. Comprehensive, coordinated edits and workflow management

tools, including those described below, will identify and address potential data issues at the

earliest opportunity. MCP’s collaboration with the AHCCCS encounter processing unit

contributed to the successful acceptance of more than 99 percent of all submitted encounters in

calendar year 2010.



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MMIC will use EMS to monitor encounter submissions on a monthly basis by comparing

encounter production to revenue distributed to providers, factoring in lag time. We will be able

to identify and respond to a provider‘s over- or under-production of encounters in a timely

manner. Additionally, we will also be able to monitor encounter production by service delivery

site, and have procedures in place to respond to outliers.

Completeness, Timeliness and Accuracy

Claims Processing: Our core claims and eligibility processing system, QNXT™, will use a

series of active claim edits, including state reference file information, to determine whether

select claim fields contain required values, and will deny completely, or in part, claims submitted

with missing or invalid information. The provider must then resubmit the claim with complete,

valid information to receive payment. To better support improved processing, completeness and

accuracy, MMIC will reconcile our member files with AHCCCS' monthly 834 transaction, then

resume posting daily 834 transactions, reporting any discrepancies to AHCCCS' Member File

Integrity Services Unit.

Encounter Staging Area: Upon successful adjudication and payment within QNXT™, claims

will be exported to the EMS encounter staging area, a quality control measure utilizing

intermediate data tables, wherein receipt of all claims data will be verified by way of a transfer

validation report, reconciling the paid claim counts in the system to those in EMS. Valid claims

data will then be loaded into EMS, while encounter management staff will research, track and

report any discrepancies to resolution.

EMS Scrub Edits: Encounter management and staff will design and apply custom AHCCCS-

specific edit profiles to encounter data in EMS, aligning our internal encounter edit configuration

with that of AHCCCS. The result of this process will be improved encounter acceptance rates,

as data unlikely to pass AHCCCS edits are pended or rejected until the underlying issue can be

identified and resolved.



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Encounter Tracking Reports: Encounter management and staff will utilize a suite of reports to

monitor, identify, track and resolve issues concerning encounter data at any point in the

submission process. These reports will enable us to monitor the status of each encounter in

EMS, providing accurate, timely and complete submission of data to AHCCCS. They will make

sure that encounter data arrives no later than 210 days after the end of the month when the

service was rendered, or the effective date of enrollment with MMIC, whichever is later.

Additionally, pharmacy-related encounter data will also arrive no later than 30 calendar days

after the end of the quarter in which the pharmaceutical item was dispensed.

Encounter Aging Reports: These reports will provide the aging and status of any encounter in

process, enabling encounter management staff to prioritize their efforts, further supporting the

accurate, timely and complete submission of data.

Review & Verification: As part of our continuous process improvement activities and

compliance procedures, MMIC will periodically conduct scheduled chart audits, comparing

providers' medical records to claims data, to verify that there are no discrepancies between the

service codes, number of units and diagnosis codes documented in the medical record and

submitted claims data. We will cooperate with AHCCCS' annual encounter validation studies by

coordinating collection of member medical records from providers.



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17.11.8 Monitoring Encounter Submissions Monthly

17.11.9 Identification and Response to Providers’ Over- or Under-Production of

Encounters

17.11.10 Monitoring Encounter Production by Service Delivery Site

MMIC will continually monitor claims processing and work with providers to resolve any claims

and encounters issues in a timely manner. The goal will always be reducing confusion at the

provider level. MCP created its Health Plan Operations (HPO) team in April 2009 to address

provider complaints and claims processing issues. The team, led by the Vice President of Health

Plan Operations, is responsible for the approval and validation of all system changes related to

claims adjudication activities.

Under the COO's oversight, the team follows the Plan-Do-Study-Act (PDSA) model for

continuous improvement, identifying opportunities for improvement via:

Monthly meetings on clinical edits

Weekly cross functional meetings

Claim reports that target, track and trend claims-related issues

Direction and validation of any new system configurations and contracts

Regular monitoring of AHCCCS website for required updates

Research and resolution of all provider complaints about claims payment

Issues identified in claim audits

Encounter pends and denials

Audits of the system benefits by the HPO department

Targeted claims review

The HPO team researches all issues identified by the various sources, and implements system

changes, provider record changes, claims P&Ps changes, and corrective action plans, then

validating all changes, evaluating the results, and repeating the process to promote continuous



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improvement. It tracks all issues and corrective action plans in a QuickBase database until they

are resolved. Recent successes include the transition from manual downstream provider file

maintenance to an automated front-end process that downloads provider files directly from

AHCCCS, resulting in significantly higher claims processing accuracy.

MMIC's Provider Claims Educator will support its HPO team by facilitating the inter-

departmental exchange of information and the external exchange of information between these

departments and our providers. We will then inform providers of any issue(s) potentially

impacting claim adjudication, or any opportunities for provider education.

MMIC will utilize a suite of tools, including scheduled and ad hoc reports to monitor claim

receipts, automated claims processing, manual claims adjudication, and check and remittance

advice production/distribution. These tools and reports will include:

Pended Claims and Aging Report – It will allow management to effectively intervene,

when and where necessary, to improve accurate and timely adjudication of claims. Populated

hourly and reviewed daily, the report will present claims counts and billed dollars by pend

reason and claim age, with drill-down capabilities to gather detailed claims information for

review.

In-Process Claim Reports – Our Claims and Health Plan Operations Department will daily

review and monitor the in-process claims report to enable management to effectively track

and manage all claims, so needed interventions may be applied to improve the accuracy and

timeliness of adjudication.

Claims Payment Processing Reports – This set of retrospective claims adjudication reports

will be produced and reviewed weekly to provide the Claims department, Health Plan

Operations, and the Finance department data to support reconciliation of claim volume and

adjudicated dollars, including information to support the reinsurance process.



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Monthly Claims Dashboard – AHCCCS will use this management tool to identify trends

related to critical claims metrics. The claims dashboard is reviewed monthly by the

following departments to identify appropriate action plans: Compliance, Encounters, Health

Plan Operations, and Finance.

On a daily basis, MMIC will use these reports to proactively manage claims workflow. Based on

this analysis, HPO will take appropriate action to address any trends that indicate a potential

issue, such as turnaround times or inventory levels for aging claims. It will be our standard

operating procedure to immediately determine a root cause and implement the appropriate action

plan. These plans will include system reconfiguration, staff overtime, workload balancing,

additional training of staff and providers, and hiring and training temporary workers to assist

with the reduction of claim inventories. Based on our claims volume, we will adjust hiring to

accommodate any increased trends. Additional information on our claims monitoring and

resolution of deficiencies process can be found in an illustration following our response.

Claim Quality Reviews and Claim Audits

MMIC will fully audit the work of all new Claims Analysts after they complete their orientation

and training for a minimum of one month. Initially, we will review 100 percent of their work

product and, by percentage tiers, decrease to a standard two percent by the fifth week, provided

the new Claims Analyst continues to meet claims accuracy standards. Finally, we will review 16

provider calls per Claims Inquiry Representative per month to assess the quality of service

interaction and the accuracy of information provided. We will present individual quality reports

to the Representative and Supervisor for corrective action, such as live call monitoring, if

appropriate.

Our Claims Audit Department will conduct a series of pre-payment audits, including a one

percent random sample of system-adjudicated claims; a two percent random sample of all

analyst-adjudicated claims; and 100 percent of claims with billed charges above $50,000. When



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we discover pre-payment errors during these audits, we will pend claims for analysis and

adjusted as required for final adjudication. If an adjudication error indicates a system

configuration problem, we will route the issue to Health plan Operations personnel for further

review, analysis, testing and correction. If adjudication errors are identified relative to manually

adjudicated claims, we will conduct a review of P&Ps and additional analyst training. If our

audit identifies a provider billing issue, we will forward the information to Provider Services

personnel for provider outreach and education as necessary. To further support quality reviews

of claims processing accuracy for acute, HCBS and other specialty claims, an independent post-

payment audit department will be responsible for conducting stratified random samples and

focused audits of paid and denied claims. The purpose of these activities will be to audit

compliance of claims adjudication with AHCCCS regulatory requirements and provider

contracts. We will distribute audit findings to HPO for root cause analysis and corrective action.

Per the ACOM Verification of Receipt of Services Policy, Mercy Maricopa Integrated Care

(MMIC) will survey a sample of our membership on a quarterly basis to verify that reimbursed

services are, in fact, delivered. Any service authorized but not performed within the allotted time

is flagged for investigation by quality management staff.



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17.11.7 Verification Of Encounters For Services (42 CFR 438.455(1)(a)(2)).

17.11.11 Attestation Of Encounter Data Accuracy, Completeness and Truthful

17.11.12 Collecting And Verifying Reported Data Accuracy and Timeliness (42 CFR

438.242(b)(2)).

Certification: MMIC will include with any encounter submission a certification signed by the

CEO, CFO, or designee attesting that listed services were actually rendered [42 CFR

455.1(a)(2)]. We will submit encounters AHCCCS in its prescribed format.

Submission: MMIC will create HIPAA-compliant encounter files according to AHCCCS'

submission requirements and schedule.

Encounter Error and Acceptance Reports: Generated upon receipt of AHCCCS' response

files (277, 277U, NCPDP / PAH - post adjudicated history), these reports will include the age

and description of submission errors and provide necessary information for encounter

management staff to promptly identify, track and resolve encounter errors. Should a claim

require re-adjudication as the result of an encounter error, we will resubmit it to QNXT™ for

processing, and import it to the EMS for resubmission to AHCCCS, in accordance with

encounter correction protocol. EMS will then generate, as required, the appropriate void,

replacement and/or corrected records. If re-adjudication is unnecessary, the encounter

management unit will perform the corrections necessary to allow resubmission of the associated

encounter per protocol.

Reporting: MMIC's policies and procedures will comply with AHCCCS requirements regarding

reports, content and frequency of submission, providing for AHCCCS receipt of any deliverable

(for example, Corrected Pended Encounter Data, New Day Encounters or Medical Records for

Data Validation) by 5 p.m. on or before the indicated due date or, should it fall on a weekend,

state mandatory furlough day or holiday, by 5 p.m the next business day. For an example of

accuracy submission, please see Table 1 below:



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Table 1: Accuracy Submission Plan ID

Plan Name YEAR MONTH Accepted

Total Sent

Accuracy %

MCRP MCRP 2012 1 1049316 1070101 98%

MCRP MCRP 2012 2 1282618 1309030 98%

MCRP MCRP 2012 3 1176188 1206079 98%

MCRP MCRP 2012 4 1015413 1052768 96%

MCRP MCRP 2012 5 1201785 1243497 97%

MCRP MCRP 2012 6 241793 268435 90%

Reinsurance Eligibility/Aging Reports: To maximize utilization of the AHCCCS reinsurance

program, MMIC’s Finance department will manage a separate, closely coordinated process,

wherein dedicated staff will run a monthly query against QNXT™ to identify, through

predetermined thresholds, claims eligible for reinsurance. They will then compare these claims

to EMS to isolate pended or denied encounters less than three months from their respective

Prepaid Medicaid Management Information System (PMMIS) adjudication deadlines, allowing

them to prioritize and handle them accordingly. Staff will void encounters for any claims

recouped in full, with replacement encounters submitted when any recoupment/adjustment

results in reduced/increased claim value. Training and internal policies and procedures will

address the specific nuances associated with the four types of reinsurance cases.

Remediation Strategies

MMIC’s Health Plan Operations (HPO) team, under the direction of the Vice President of HPO,

will be supported by two Encounter Specialists who research each pend or denial edit from

AHCCCS. The team will employ diverse strategies to track related issues to their point of origin,

utilizing continuous improvement methodologies to identify, assess, remediate and control

sources of error:

Manual Adjudication: MMIC’s standard operating procedures will utilize aggressive measures

to address Claims Analyst error with regard to procedural, payment or financial accuracy. These



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procedures will include documented coaching, Performance Improvement Plans and, if

necessary, further corrective action up to termination. If a manual adjudication error is traced to

an existing claims policy and procedure, a Claims Training Update (CTU) will be distributed to

Claims Analysts to prevent further errors. We will update policies and procedures, along with

training materials, as necessary.

Auto Adjudication: To validate correct application to all submitted claims processing, the HPO

team will review all encounter edits, pends and denials in relation to the QNXT™ system set up

for member enrollment, benefits, edits, provider set-up and reference files. The HPO team will

pend and adjust impacted claims in process, if necessary, and adopt manual workarounds as

needed until the issue is resolved.

Provider Education: The HPO department will identify opportunities for targeted provider

education regarding specific errors related to unacceptable claim and billing practices. Based

upon specific identified errors, HPO will work with Provider Services personnel to complete

outreach, education and training for providers. They will concentrate on reducing the frequency

of providers with a history of submitting incomplete, inaccurate or untimely claims by way of

additional training and support.

Encounter Workgroup: The HPO department will lead cross-functional group comprising

System Configuration Specialists, Provider Claim Educator, and personnel representing IT,

claims and claims audit departments, compliance, encounters, provider data management and

services and the Medicaid Provider Solutions Team. This workgroup will meet weekly to address

issues with resolving pends and denials, improving workflows, and any open encounter system

concerns.

Collaboration: MMIC personnel will attend a monthly meeting wherein encounter management,

claims, compliance, finance, and HPO personnel collaborate with AHCCCS staff to resolve

pended encounter issues.



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MMIC will follow the lead of our sponsor, MCP, in all of the above. Examples of its HPO

team's success include:

Recognizing that manual input and maintenance of data poses an unnecessary risk to the

accuracy of provider information, MCP implemented an automated front-end process,

downloading provider reference files from AHCCCS every two weeks, then editing against

them to mitigate associated downstream errors.

When MCP identified improper configuration of edits related to "age" and "maximum units

available" as a source of error, it reconfigured edits, and modified the process for maintaining

them to utilize AHCCCS reference files.

Following MCP’s example, our HPO team will monitor all claim audit findings and Claim

Dashboard results, and will approve and validate all system changes, such as reference file and

fee schedule updates, as well as benefit changes. This team will also be responsible for post-

production validation of all claim processing-related projects and system change activities.

Flowcharts illustrating MMIC's encounter submissions process can be found as Figure 7 at the

end of this section.

Encounter Submission Initial and Global Acceptance Rates

MMIC will adopt MCP’s processes, which have resulted in superior encounter submission

acceptance rates with AHCCCS as evidenced in Tables 2-3 on the following pages.



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Table 2: Initial File Acceptance (Month of Submission regardless of DOS)

Plan ID Plan

Name YEAR MONTH Sum of

Accepted Sum of Total

Sent Accuracy %MCRP MCRP 2011 1 1246404 1267766 98%

MCRP MCRP 2011 2 1316112 1337949 98%

MCRP MCRP 2011 3 661447 677632 98%

MCRP MCRP 2011 4 1794804 1828407 98%

MCRP MCRP 2011 5 1706612 1735152 98%

MCRP MCRP 2011 6 1326277 1398988 95%

MCRP MCRP 2011 7 1053395 1070014 98%

MCRP MCRP 2011 8 1395783 1493143 93%

MCRP MCRP 2011 9 1151704 1181793 97%

MCRP MCRP 2011 10 1158826 1188320 98%

MCRP MCRP 2011 11 1371028 1394603 98%

MCRP MCRP 2011 12 880702 910403 97%

MCRP MCRP 2012 1 1049316 1070101 98%

MCRP MCRP 2012 2 1282618 1309030 98%

MCRP MCRP 2012 3 1176188 1206079 98%

MCRP MCRP 2012 4 1015413 1052768 96%

MCRP MCRP 2012 5 1201785 1243497 97%

Table 3: Global File Acceptance: Overall Accuracy

(MOS view for 2012 DOS regardless of submission date - numbers will change as claim lags process through

claims and encounter systems)

Plan ID Plan

Name YEAR MONTH Accepted Total Sent Global

Accuracy %MCRP MCRP 2011 1 1272777 1300777 97.8%

MCRP MCRP 2011 2 1208647 1241589 97.3%

MCRP MCRP 2011 3 1287638 1314745 97.9%

MCRP MCRP 2011 4 1196145 1218446 98.2%



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Plan ID Plan

Name YEAR MONTH Accepted Total Sent Global

Accuracy %MCRP MCRP 2011 5 1174510 1195004 98.3%

MCRP MCRP 2011 6 1124083 1193871 94.2%

MCRP MCRP 2011 7 1113886 1131923 98.4%

MCRP MCRP 2011 8 1157333 1229152 94.2%

MCRP MCRP 2011 9 990840 1005557 98.5%

MCRP MCRP 2011 10 991064 1003533 98.8%

MCRP MCRP 2011 11 763603 772494 98.8%

MCRP MCRP 2011 12 171584 173831 98.7%

The following chart illustrates 12 months of MCP encounter acceptance data with AHCCCS by

hospital systems, physicians and ancillary, and pharmacy.

Table 4: MCP Encounter Acceptance Data (12 months) Form Type 2011 JAN FEB MAR APRIL MAY JUNE JULY AUG SEPT OCT NOV DEC

1500 97.86% 97.77% 97.83% 97.95% 98.07% 98.01% 98.24% 98.16% 98.67% 98.82% 98.77% 99.26%

Dental 99.78% 99.75% 99.65% 99.70% 99.75% 99.74% 99.79% 99.69% 99.74% 99.79% 99.79% 100.00%

NCPDP 97.45% 95.96% 97.84% 98.43% 98.55% 83.51% 98.63% 83.61% 98.52% 98.45% 98.76% 98.62%

UB04 97.08% 96.93% 96.70% 96.87% 97.04% 96.93% 96.40% 95.31% 94.19% 96.91% 98.61% 99.03%

MMIC’s sponsor Mercy Care Plan (MCP)’s experience in claims and encounter processing will

allow us to continue to refine and bolster our internal procedures. We will leverage MCP’s

expertise in this arena to effect changes in the way we will deliver health care to our members

and enhance our ability to serve diverse populations. Figures 2-5 on the following pages outline

our claims processing flows.

Also, please see the Attachments Tab in ProcureAZ for Mercy Maricopa Integrated Care

(MMIC)’s Sample Remittance Advice.



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Figure 2: Claims Payable Flow Chart – Electronic Claims



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Figure 3: Claims Payable Flow Chart – Paper Claims



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Figure 4: Manage Claims Editing Flowchart (3 pages)



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Figure 5: Third Party Liability (TPL) / Coordination of Benefits (COB) Process Flowchart



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Figure 6: Medicaid Pharmacy Future State Process Flows



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Figure 7: Encounter Process

17.12 Encounter Reporting When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:

Mercy Maricopa Integrated Care (MMIC) understands that to be considered an effective

organization, we must be able to report data to the regulatory agencies that is clear, concise, and

timely. We are committed to maintaining a robust encounter reporting system that serves to

report on the services we provide to our members and supports future enhancements through the

analysis of timely and complete data.



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17.12.1 Monitoring Submissions of Encounters

MMIC’s proprietary Encounter Management System (EMS) will provide for the accurate,

timely, and complete submission of encounter data, and will be used for all encounter reporting

activities. We will rely on the experience of our sponsors, Mercy Care Plan (MCP) and

Maricopa Integrated Health System (MIHS), to successfully process encounters for both

Medicaid and the Medicare/Medicaid dual eligible programs. Through EMS, MMIC will be able

to submit reports to ADHS/DBHS for tracking, trending, reporting process improvement, and

monitoring submissions of encounters and encounter revisions in conformance with the

AHCCCS Encounter Manual, or as directed by ADHS/DBHS (42 CFR 438.242(b)(3)).

17.12.2 Loading Periodic Data Files

To comply with contractual requirements and enhance the accuracy of our encounter reporting,

MMIC will load, at a minimum, twice monthly, data files containing provider and medical

coding information as defined in the AHCCCS Encounter Manual.

17.12.3 Monitoring Contractor’s Encounters Adjudication Accuracy

17.12.4 Monitoring and Reporting the Completeness of Encounters

Under the direction of the MMIC Encounters Director, encounter management personnel will be

responsible for managing encounter inventory using the following controls:

Monthly review of GLB Dashboard by Encounter Management and Project Managers

Weekly review of Progress Tracker by Encounter Management and Project Managers

Weekly review of GLB Compliance Dashboard by Encounter Management and Project

Managers



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Weekly meetings held with encounter management and plan-specific teams to discuss aging

of encounter inventory

Weekly meetings with the Medicaid health plans to discuss aging of encounter inventory

Monthly CPSO Results report, outlining encounter inventory, to CPSO executive

management

The staff will cooperate with ADHS/DBHS in monitoring MMIC‘s encounters adjudication

accuracy against our internal criteria. These controls will allow us to track, monitor and correct

all encounter errors, so we can verify the accuracy of information reported to ADHS/DBHS and

AHCCCS.

17.12.5 Quarterly Fee for Service Check Register Review Report

17.12.6 Encounter Reconciliation Files

17.12.7 Compare Encounter Financial Data Reported with Plan Claims Data

Encounter Tracking Reports: MMIC Encounter management staff will utilize a suite of reports

to monitor, identify, track and resolve issues concerning encounter data at any point in the

submission process. These reports will allow us to monitor the status of individual encounters

within the Encounter Management System (EMS) to facilitate accurate, timely and complete

submission of encounter data to AHCCCS – thus delivering that encounter data no later than 210

days after the end of the month in which the service was rendered or the effective date of MMIC

enrollment, whichever is later. Additionally, we will submit pharmacy-related encounter data no

later than 30 calendar days after the end of the quarter in which the pharmaceutical item was

dispensed.

Encounter Aging Reports: These reports provide the aging and status of any encounter in

process. Reviewing these reports will allow encounter management staff to prioritize their



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efforts to track movement through the system, as well as detect and resolve any errors, further

supporting accurate, timely and complete submission of data.

Encounter Error and Acceptance Reports: Generated upon receipt of AHCCCS’ response

files (277, 277U, NCPDP, PAH Post Adjudication History), these reports will include the age

and description of submission errors. They will provide the information necessary for encounter

management staff to promptly identify, track and resolve errors. Should a claim require re-

adjudication as the result of an encounter error, it will be resubmitted to QNXT™ for processing,

with an adjusted claim imported to the EMS for resubmission to AHCCCS in accordance with

encounter correction protocol. EMS will then generate, as required, the appropriate voided,

replacement and/or corrected records. If re-adjudication is unnecessary, the encounter

management unit will perform necessary corrections to allow resubmission of the associated

encounter per protocol.

Reinsurance Eligibility/Aging Reports: To maximize utilization of AHCCCS’ reinsurance

program, MMIC’s Finance Department will manage a separate, though closely coordinated

process, wherein dedicated staff will run a monthly query against QNXT™ to identify, given

predetermined thresholds, claims eligible for reinsurance. These claims will then be compared to

EMS to isolate pended or denied encounters less than three months from the respective Prepaid

Medicaid Management Information System (PMMIS) adjudication deadline, allowing

reinsurance staff to prioritize and handle them accordingly. Encounters for any claims recouped

in full will be voided, with replacements submitted in the case of any recoupment/adjustment

resulting in reduced/increased claim value. Training and P&Ps will address the specific nuances

associated with the four types of reinsurance cases.



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Additional Reports will be used to determine the accuracy levels of encounter reporting,

including:

Encounter Correction Analyst Workflow Report (weekly/ad hoc)

Encounter Error Crystal Report (daily)

Encounter Financial Reconciliation Report (quarterly)

File Transfer Validation Crystal Report (daily/weekly)

Flash Metric Report (daily/weekly)

GLB Compliance Dashboard (monthly)

GLB Dashboard (weekly)

Master Encounter Inventory Report (weekly)

Progress Tracker (weekly)

State Dependent Encounter Status Report (monthly)

MCRP Top 10/5 Error Report (weekly)

Timely Reporting: MMIC’s reporting process will comply with ADHS/DBHS’ and AHCCCS’

requirements regarding reports, report content and frequency of submission, utilizing internal

policies and procedures that provide direction to guarantee AHCCCS’ receipt of any deliverable

by 5:00 p.m. on or before the due date indicated or, should the due date fall on a weekend, state

mandatory furlough day, or a state holiday, 5:00 p.m. the next business day.

Our timely reporting policies and procedures will direct claims management staff to submit the

Quarterly Fee for Service Check Register Review report ten (10) business days after the first

(1st) of the month following the quarter to be reviewed per the ADHS/DBHS Operations and

Procedures Manual. Also, as required, MMIC will accept, on a monthly basis, encounter

reconciliation files containing the prior eighteen (18) months of approved, voided, plan-denied,

pended and AHCCCS-denied encounters received and processed by AHCCCS.



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MMIC will utilize the encounter reconciliation files to compare the encounter financial data

reported with the plan claims data, and to validate the completeness of submitted encounters as

compared to processed claims. To verify accuracy, MMIC has developed and will implement a

system for monitoring and reporting the completeness of encounters and encounter data

processed internally and received from subcontractors and providers. MMIC understands the

importance of maintaining a robust encounter reporting system, and we are committed and have

systems in place to provide accurate, timely, and complete submission of encounter data.

17.13 Encounter Corrections When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:

Mercy Maricopa Integrated Care (MMIC) recognizes that it is critically important to obtain

timely, accurate, and complete encounter submissions from providers. MMIC will take a multi-

pronged approach to make sure that encounter submissions are successful, including: adherence

to our written Policies and Procedures, provider contract requirements, training and interactive

tools, sanctions, and recoupments. We will monitor encounter reporting on a weekly basis and

encounters will be subject to data validation audits. MMIC will also work with the providers on

pended encounters in a proactive fashion in order to minimize/eliminate the number of

encounters aging past 120 days. MMIC will support its providers that are going to submit

encounters from day one of the start of the program. We understand the frustrations of providers

when they lack the experience or the knowledge necessary to successfully submit encounters.

Therefore, we will offer a training module for providers that is dedicated to encounter

submission; it will be detailed in our provider training plan that will be submitted to

ADHS/DBHS for review as directed, during implementation. Upon approval of the Department

and prior to contract start and we will initiate training. Ongoing monitoring and continued

follow-up and support will be provided.



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As part of our corporate principles, we will hold our staff to the highest level of competency

when dealing with encounter data. MMIC, through its sponsors, will bring experience and

commitment regarding data accuracy and integrity into every facet of our organization. Staff

will be trained to effectively utilize the knowledge they gain, therefore delivering quality

outcomes at every step of the process.

17.13.1 Monitoring and Resolution of Pended Encounters

MMIC will establish best practices regarding the monitoring and resolution of encounter issues.

An active hands-on approach will be taken by the MMIC Encounter Unit staff to identify

consistent data issues. The proprietary Encounter Management System (EMS) will provide for

the accurate, timely and complete submission of encounter data. MMIC will leverage the

experience in processing medical, behavioral health and Medicare claims of our sponsor

agencies and instill the same quality in monitoring and resolving encounter issues. MMIC will

utilize the following documents to achieve full compliance in its efforts to collect, analyze,

integrate and report data:

AHCCCS HIPAA Transaction Companion Guides & Trading Partner Agreements;

AHCCCS Encounter Manual;

AHCCCS Technical Interface Guidelines; and

Client Information System (CIS) File Layouts and Specifications Manual.

Encounter corrections will be processed in EMS. The EMS meets the AHCCCS requirements for

encounters corrections by identifying encounter errors timely and correcting them immediately.

If re-adjudication is not necessary, mass corrections can be implemented so that records can be

re-submitted as quickly as possible. Records requiring re-adjudication will be automatically

accounted for as the corrected-claims data is loaded into the system. The system will generate

the appropriate void, replacement and/or corrected records as required. Mass correction logic is



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then translated into a scrub edit that proactively identifies and flags affected records prior to

submission as part of the data validation process.

Reports that will be utilized by the Encounter Unit staff to identify and correct encounter errors

include:

Error Reports (weekly, monthly)

Third Party Encounter Error Report (weekly)

Provider Error Report (weekly)

Member Error Report (weekly)

Under the direction of the Encounter Management Team, the Encounter Unit will be responsible

for correction of encounter data. The Encounter Management team reviews, approves and

communicates associated updates of state, federal or health plan encounter changes to

Information Technology (IT).

To identify and quantify all encounter errors by type, age and to confirm that each is resolved

and resubmitted accurately and on a timely basis, MMIC will implement the following measures

for Encounter staff to achieve:

Correction rate of four (4) claims/encounters per hour

Meet state requirements as defined in the Encounter Timeliness and Accuracy Requirements

Tool Kit

Achieve 100%, plus or minus 3%, encounter acceptance of finalized claims and dollars paid

in the claims processing system

Encounter remittance information is integrated with existing encounter submission data for the

following objectives:

Update the encounter status

Monitor/report encounter submission results



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Identify encounter issues

The Encounter Unit will utilize the knowledge and strengths of specially trained encounter

correction analysts who bring extensive experience in claim adjudication and claim research to

their role. These highly skilled analysts are dedicated to researching and resolving unique

encounter issues.

17.13.2 Be Subject to Corrective Action or Financial Sanctions for Poor Overall Encounter

Performance

MMIC will accurately verify and document performance problems during the encounter process.

With proper monitoring such as weekly encounter reports, data validation audits, and technical

assistance to providers, MMIC will be able to begin corrective action as soon as it may be

required. MMIC will identify the problem with the provider and seek their commitment to take

remedial action. Once the plan is in place, MMIC will use data validation audits to follow up

and validate correction. If a provider is found to be in noncompliance, MMIC will administer

follow-up steps which could include sanctions, fines or potential recoupment based upon the

severity of the issue. MMIC understands that it could be subject to corrective action or financial

sanctions and will submit to ADHS 90 percent (90%) of encounters for all services within one

hundred twenty (120) days and 95 percent (95%) of encounters for all services within one

hundred eighty (180) days fully complying with requirements for timelines, accuracy, and

omission of data in accordance with ADHS/DBHS Office of Program Support Procedures

Manual.



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17.13.3 Submit Replacement or Voided Encounters for Claims Subsequently Corrected

17.13.3.1 Void Encounters for Claims that are Recouped in Full

MMIC will submit a void request to ADHS/DBHS. MMIC will document the reason the

encounter was deleted and maintain a record of the deleted Internal Control Number (ICN).

Replacement encounters will be submitted for pended encounters for AHCCCS member ID,

service provider ID, plan ID, financial data, paid units, payer data and claim adjustment status

data as required.

17.13.3.2 Submit Replacement Encounters for a Recoupment that Results in a Reduced Claim Value

MMIC will submit replacement encounters in conformance with the AHCCCS Encounter

Manual. In addition to the replacement, MMIC will also include the following as required: the

systemic causes resulting in the need for the refund and/or an explanation of why the refund

occurred, the corrective actions that will be implemented to avoid future occurrences, if

applicable, cumulative refund amount, total number of claims and range of dates for the claims

impacted by the refund.

17.13.3.3 Submit Replacement Encounters for Recoupments Requiring Approval from ADHS/DBHS or AHCCCS

MMIC’s Claims Administrator, John Monte is responsible for the establishment of written

Policies and Procedures that direct our encounter and recoupment processes. Our P & Ps will

require that we always obtain ADHS/DBHS’ prior approval for any individual recoupment in

excess of fifty thousand dollars ($50,000) per provider within a contract year, and to notify

ADHS/DBHS of any cumulative recoupment greater than fifty thousand dollars ($50,000) per

provider Tax Identification Number per contract year. We will only submit replacement

encounters for recoupments with ADHS/DBHS/AHCCCS approval. Weekly recoupment reports



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will be monitored by the MMIC Finance department to verify compliance with the requirement

and to identify track trends and issues.

By following our dynamic oversight processes for the management of encounters, our processes

will be consistent and the flow of information from claims to MMIC’s other operational and

clinical departments will be smooth. This will enhance our company’s agility and

responsiveness to changing conditions. Additionally, the steps followed in our encounter

management and recoupment processes will enable us to accurately identify, manage and reduce

risk exposure, improve member service, gain operational efficiency, and adapt to change quickly.

17.14 AHCCCS Encounter Data Validation Study (EDVS) When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:

17.14.1 Cooperate with ADHS/DBHS and AHCCCS to Conduct an Annual Encounter

Data Validation Study

MMIC will cooperate with ADHS/DBHS and AHCCCS to conduct encounter data validation.

MMIC will require providers to bill services using a diagnosis code that is documented in the

service recipient’s medical record and in effect at the time the service was provided. Diagnosis

codes will be required to be clearly documented in the provider’s recipient medical records.

Examples of valid diagnosis code documentation include an annual assessment, most recent

doctor’s note (where the diagnosis was changed), or other appropriate documentation signed by

someone who is properly licensed and credentialed to determine a service recipient's diagnosis

code as defined in R9-20-209, Universal Rules, Assessment and Treatment Plan, of the Arizona

Administrative Code. If the diagnosis code changes over the course of the service recipient’s

treatment, that change must be documented and any services provided after the change are

required to be billed using the new diagnosis code.



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Figure 1 below illustrates the process our sponsor agencies use, which MMIC will leverage to

extrapolate the data requested by AHCCCS for the Encounter Validation Study.

Figure 1: Data Validation Workflow Chart

17.14.2 Be Subject to Sanctions for Failure to Meet the Criteria Used in Encounter Data

Validation Studies

17.14.7 Be Responsible for All Sanctions Imposed Against ADHS/DBHS by AHCCCS

MMIC is keenly aware that reporting inaccuracies is not acceptable to AHCCCS, and we

understand that we may be subject to sanctions for failure to meet the criteria used in encounter

data validation studies, which may include timeliness, correctness, and omission of encounters as

described in Exhibit 7, AHCCCS Data Validation Technical Assistance Document. We are also



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aware that inconsistencies in our encounter validation processes may hold us responsible for all

sanctions imposed against ADHS/DBHS by AHCCCS as a result of data validation studies

according to the process in Section 19.5.9.

17.14.3 Comply with any Revisions Made by ADHS/DBHS or AHCCCS to the Study

Methodology, Timelines, and Sanction Amounts Based On Agency Review

17.14.4 Cooperate with ADHS/DBHS or AHCCCS in Special Reviews of Encounter Data

17.14.6 Conduct Targeted Encounter Data Validation Studies

MMIC will comply with any revisions made by ADHS/DBHS or AHCCCS to the EDV Study.

We will also notify all contracted providers of changes through written communication of any

significant change in methodology. In addition to communications, MMIC will incorporate the

change within provider training modules. An example would be if changes to our audit

methodology related to assessments and service plans occurred, then these tools would be

updated for providers. By doing this, MMIC will be able to implement this change in its

quarterly data validation audits in order to implement a seamless transition of the change.

As part of MMIC’s continuous improvement project, we will conduct targeted encounter

validation studies on providers who are found to be noncompliant. These audits and their

findings will be made available to ADHS/DBHS upon request. We will have a well-defined

Encounter Data Validation Study process as outlined in the following steps. The following areas

of study are included in the electronic file match: acute, ALTCS, dental, case management, non-

emergency transportation, and pharmacy studies.

1. Approximately nine months after the end of a contract year for AHCCCS validation and

quarterly for ADHS/DBHS requirements, encounter extract files by the Contractor will be

requested through the Information Management Subsystem on the Prepaid Medicaid



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Management Information System (PMMIS). Files for each Contractor are downloaded and

the sample list of members by Contractor is generated.

2. The sample list is sent to each Contractor, with a request for PCP information and medical

record files from the sample members’ PCPs.

3. The Contractors give the Encounter Validation Unit a list of PCPs by sample members. This

information will be used to request the medical records directly from PCPs.

4. PCPs send copies of the members’ medical record files to the Encounter Validation Unit.

5. The number of medical record files received will be tracked. Status reports will be sent to the

Contractors until sufficient medical record files have been received.

6. MMIC will work with providers to obtain medical records that are outstanding.

MMIC’s sponsor agencies have developed and implemented a collaborative process for working

with providers on correct encounter submissions. In our sponsors’ Patient-Centered Medical

Home (PCMH) models, they provide claims and encounter data to providers to assist them in

understanding member medical trends. MMIC will implement a similar approach in order to

continuously educate our providers about correct and timely encounter and data submission.

17.14.5 Conduct Encounter Data Validation Studies of Subcontractors

MMIC will properly conduct validation audits so that covered behavioral health services are

appropriately documented and billed/encountered and that they support the identification of

opportunities for improvement in billing practices. MMIC will perform data validation studies

of our providers on a quarterly basis at the minimum per Branch for Program Operations Office

of Program Support Operations and Procedures Manual. MMIC will verify that all services

delivered to MMIC members are being reported accurately, timely and are documented in the

medical record. MMIC will conduct targeted encounter data validation studies of providers that

are not in compliance with ADHS/DBHS or MMIC’s encounter submission requirements.



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MMIC will document the results of encounter data validation studies and provide the findings to

ADHS/DBHS upon request. In addition, MMIC will report summary findings to ADHS/DBHS

Compliance quarterly.

At a minimum, the following information will be provided in the quarterly report based on the

prescribed reporting format: Med Records Reviewed, Non-Compliant Assessments, Total

Encounters Reviewed, and Total Encounters with Errors, Type of Service Code Error, and Error

Issue. In addition, MMIC may collect the following areas that will not be included in the error

rate calculation. However, these areas will be addressed as findings in the audit report:

documentation that the provider screened the service recipient for TXIX/XXI eligibility in

accordance with Section 4.2.6-D; Behavioral Health Medical Record Standards; Comprehensive

Clinical Record of the Provider Manual; documentation that the provider screened the service

recipient for Medicare and third party liability (TPL) insurance in accordance with Section 3.5,

Third Party Liability and Coordination of Benefits, of the Provider Manual; provider billed

services to Medicare and TPL prior to MMIC, when applicable, in accordance with Section 3.5,

Third Party Liability and Coordination of Benefits, of the Provider Manual; medical record

includes a HIPAA access log as required in Section 4.1.7-B, General Procedures for All

Disclosures, of the Provider Manual; provider makes amendments to medical record

documentation using the process described in Section 4.2.6-A, Behavioral Health Medical

Record Standards, of the Provider Manual; document services on the date the service was

provided or otherwise identify the note as a late entry as required in Section 4.2.6-A, Behavioral

Health Medical Record Standards, of the Provider Manual; and Section R9-20-211(C), Client

Records, of the Arizona Administrative Code.

MMIC will bring a wealth of tools and resources for use in the EVDS both in collaboration with

AHCCCS as well as studies as required by ADHS/DBHS. We will demonstrate our



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understanding of the critical role that providers play in the care of our members. The studies can

bring to life areas for improvement, compliance and risk reduction, but most importantly, will

help to improve the lives of the people we serve and the health of our communities.



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17.15 Claims Payment System Requirements When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:

Mercy Maricopa Integrated Care (MMIC) values members’ rights to privacy, and views

protecting their personal health information as paramount. Based on this belief, we have

developed and maintained a HIPAA-compliant claims processing and payment system capable

of processing, controlling costs and paying claims in accordance with all regulatory

requirements.

MMIC’s Information Technology (IT) staff, under the direction of the Information Systems

Administrator, will review all strategies for implementing its Management Information System,


achieve full compliance with all contractual obligations. Key IT staff will coordinate collection,

analysis, integration and data reporting. They will utilize the following documents to assist in

implementation activities:







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17.15.1 HIPAA-Compliant Claims Processing and Payment System

17.15.1.1 Adapting to Updates 17.15.1.2 Utilize Nationally Recognized Methods to Correctly Pay Claims 17.15.1.3 Benefit Package Variations, Timeliness Standards Data Accuracy; Adherence to ADHS/DBHS and AHCCCS Policy; Provider Qualifications; Member Eligibility and Enrollment, and Over-Utilization Standards 17.15.1.4 Remittance Advice 17.15.1.5 Denial and Adjustments 17.15.1.6 Reasons for the Denial and Adjustments 17.15.1.7 Amount Billed 17.15.1.8 Amount Paid 17.15.1.9 Application of Coordination of Benefits and Co-pays 17.15.1.10 Provider Rights to Assert a Claim Dispute

17.15.6 Integrated Claims Payment System

MMIC, through a subcontract arrangement with Schaller Anderson, LLC (Schaller), an Aetna

company, and by virtue of Schaller’s existing contracts with AHCCCS, maintains a centralized,

HIPAA-compliant claims processing and payment

system. It is capable of processing, controlling costs

and paying claims in accordance with A.R.S. §§ 36-

2903 and 2904 and AHCCCS Rules R9-22 Article 7.

In fact, QNXT™, the cornerstone of its claims

adjudication process, was upgraded to version 4.8 in

January 2012 and passed an independent post-migration audit. Future plans include additional

upgrades in anticipation of approaching ICD-10 requirements.

MMIC’s business will be similar in size and operation, and this data illustrates our capacity to

process copious amounts of claims data. Schaller’s system is so effective that, for the 10 months

ending February 2011, an average of 98.8 percent of claims were finalized within 30 calendar

days or less, and 99.5 percent within 60 calendar days.

Schaller’s HIPAA-compliant, rules-based claim adjudication system has processed more than 1,214,023 claims for ALTCS lines of business from January 1, 2012, through November 30, 2012.



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Using the Plan-Do-Study-Act (PDSA) approach to performance improvement, MMIC will make

process improvements that increase our financial and payment accuracy. For example, for the

third quarter of calendar year 2012, Schaller audit results averaged 99.29 percent (financial) and

99.43 percent (payment) accuracy rates.

MMIC will leverage Schaller’s experience with processing medical, behavioral health and

Medicare claims, and understands that all three types will be included in the RBHA contract.

We will monitor both federal (CMS) and state (AHCCCS) publications, websites, and notices of

changes to maintain cutting edge systems for correct claims payment. From this information, we

will implement necessary changes to our processing edits.

Figure 1 on the following page illustrates the following: All Claims Received via EDI and All

Claims Auto-Adjudicated by Month.



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Figure 1: KIR #8 All Claims Received via EDI and All Claims Auto-Adjudicated by Month – ALL SAI

Schaller, as part of its subcontracting agreement, provides full claims administration through a

claims management organization led by a local Director of Claims. Centralizing claim

processing functions at Schaller allows MMIC to take advantage of economies of scale and

quality efficiencies. Schaller’s claim processing team adjudicates for more than a million

Medicaid lives annually.

MMIC’s Chief Operating Officer (COO) and Claims Director will have responsibility and

authority over Schaller’s claims performance. The COO will oversee the system’s full

compliance with all applicable AHCCCS and federal requirements, maintaining processes that

meet claims processing timelines, maximize cost avoidance, and minimizing claims recoupment.



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Our Claims Director will review, approve, date and sign all claims Policies and Procedures

(P&Ps) annually to verify their agreement with current practices and support continued

compliance with applicable AHCCCS standards and requirements.

The claims department will monitor and update regulatory changes monthly, and integrate them

into the editing functionality of the claims processing system. In addition, it will analyze

monthly reference files published by AHCCCS, and incorporate changes to editing, coding or

provider registration into the claims system.

Schaller’s claims system runs on a high-speed Local Area Network (LAN) and Wide Area

Network (WAN), with a cluster of servers providing built-in redundancy. It is configured to

provide all necessary computing power and redundancy. It is scalable to meet both enrollment

growth and expansions of AHCCCS specifications or requirements.

Schaller is able to add servers to increase performances vertically. They are designed to accept

increases in RAM and processing power to grow horizontally. This scalability enables the

claims system to match any escalation in volume arising from enrollment growth, while

maintaining responsiveness, up-time and performance.

Through our subcontract arrangement with Schaller, we will maintain claims processing

activities that include the application of comprehensive clinical and data-related edits to support

the efficient, effective adjudication of claims.

QNXT™, the core claims adjudication application, has data-related edits configured within its

software, and is supplemented by two clinical claims editing solutions. The first, iHealth

Technologies’ (iHealth) Integrated Claims Management Services (ICM Services), applies select

payment policies from one of the industry's most comprehensive correct coding and Medical

Policy content libraries. The second is McKesson’s ClaimCheck®, which expands those

capabilities by enabling our claims management team to define and combine specific claims data



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criteria, such as provider or diagnosis, to set up unique edits that deliver enhanced auditing

power.

Those three applications utilize historic and “new day” claims information to detect questionable

billing practices, such as new patient billing codes submitted by the same provider for the same

member within a six-month period. They also assist in identifying fraudulent and abusive billing

patterns by generating reports that indicate trending and outliers of provider billing behavior.

Inbound claims are initially reviewed for critical items, such as member eligibility, covered

services, excessive or unusual services for gender or age (“medically unlikely”), duplication of

services, prior authorization, invalid procedure codes, and duplicate claims. Claims billed in

excess of $50,000 are automatically pended for manual review, as are any requiring additional

documentation (such as medical records) to determine the appropriateness of the service

provided. Professional claims (HCFA 1500s) that reach an adjudicated status of “Pay” are

automatically reviewed against nationally recognized standards, such as the Correct Coding

Initiative (CCI); medical policy requirements, such as the American Medical Association

(AMA); and maximum unit requirements supplied by AHCCCS, with recommendations applied

during an automatic re-adjudication process. Other methodologies utilized throughout the auto-

adjudication process include Multiple Surgical Reductions and Global Day E & M Bundling.

QNXT™ Data Edits

QNXT™ has more than 400 business rules that MMIC will configure to support enforcement of

our claims policies and procedures (P&Ps). The application of specific conditions, restrictions,

and validation criteria will promote the accuracy of claim processing against AHCCCS

standards. The edits can result in claims pending or denying, depending on the editing logic. For

example, if the member is ineligible on the date of service, QNXT™ will automatically deny the

claim. If the provider of record’s category of service does not match the procedure code billed,

the claim will pend for manual review to validate accuracy of provider set-up.



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Examples of data edits specific to QNXT™ include the following:

Benefits Package Variations

QNXT™ automatically analyzes member information (age, sex, eligibility), provider registration

and licensure information (specialty and provider type), and diagnosis, CPT, REV and HCPCS

codes to determine whether specific services are covered under contract or benefit rules. If they

are not, the system will automatically deny the respective claim line. The denial will have the

appropriate HIPAA remittance remark on the EOB. MMIC will incorporate multiple business

specific requirements into the system as needed.

Data Accuracy

QNXT™ is continually updated, based on the most current code sets available (ICD-9, HCPCS,

REV, CPT codes) by year. As new codes are added, terminated or changed, we will update the

codes so the system will always be in compliance with HIPAA standards. We will also

leverage AHCCCS reference files to update our coding configuration on a monthly basis. If a

provider bills a code that has been terminated or invalidated, QNXT™ will deny the claim line

and notify the provider via remittance advice.

Adherence to Prior Authorization Requirements

QNXT™ is configured to enforce the supporting documentation requirements of certain services.

It also is capable of configuring Prior Authorization (PA) by code, provider type and place of

service. It is configured to automatically identify certain types of authorizations for Medical

Director review. Claim edit rules are set to validate the claim against network provider, member,

dates of service, services rendered and units authorized.



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17.15.2 Remittance Advice

MMIC will send related remittance advice with each payment, unless it is made by electronic

funds transfer (EFT). In that case, it must be mailed or sent to the provider, no later than the date

of the EFT.

QNXT™, our core claims adjudication application, produces a remittance advice that describes

payments and denials to providers, including the following:

An adequate description the denial and adjustments

The reasons for the denial and adjustments

The amount billed

The amount paid

Application of coordination of benefits and co-pays

Provider rights to assert a claim dispute

An example of a standard remittance advice can be found in the Attachments Tab of ProcureAZ.

17.15.3 Electronic Health Care Claim Payment/Advice 835 Transaction

17.15.4 HIPAA Securing Measurements

MMIC will submit, upon provider request, an electronic Health Care Claim Payment/Advice 835

transaction in accordance with HIPAA requirements. We will comply with the requirements in

Section 17.15.1.4 when sending remittance advices along with payment to providers. Through

Schaller Anderson, LLC, an Aetna company, MMIC will have a well-defined process for

addressing providers’ rights to file claim disputes and requests for hearing stemming from an

action issued by the health plan. Claims dispute rights are also included with each remittance

advice following adjudication of the provider’s claim.



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The Appeals department will be responsible for management of claims disputes and requests for

hearing, including documenting individual disputes, coordinating resolutions, and tracking,

trending and reporting data. Filing a claims dispute or requesting a State Fair Hearing will not

negatively affect or impact members or their providers.

Claims disputes must be filed with MMIC in writing no later than 60 days after the date of the

adverse action. Those challenging claim issues, including claim denials, must be filed with

MMIC in writing no later than 12 months from the date of service or initial eligibility posting

date, whichever is later, (for a hospital inpatient claim, the date of discharge) for which payment

is claimed, or within 60 days from the date of a timely claim submission. MMIC will strive for

timely acknowledgement and resolution of claim disputes.

We will appoint specific individuals with the requisite experience to administer the claims

dispute process and the authority to require corrective action, as noted in greater detail in other

sections of this response.

MMIC key IT staff, under the direction of the Information Systems Administrator, will review

all strategies for implementing the Management Information System, claims and encounter

processing and other systems that rely on data or data processing to achieve full compliance with

all contractual obligations. They will coordinate MMIC’s efforts to collect, analyze, integrate

and report data.

Member privacy and data correctness are key values of our company. We will spend significant

time and effort to protect our members’ privacy and their personal health information. MMIC is

committed to providing the most accurate, timely claims processing system in the health care

arena. Our dedication enhances the way we deliver health care to our members.



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17.15.5 National Provider Identifier

QNXT™ provider files are configured by specialty and category of service, according to

information from the AHCCCS reference files. This enables enforcement of categories of service

and provider type on claims validation. Certain procedures can only be performed by select

network provider types. For example, QNXT™ will not permit the processing of a claim for in-

office heart surgery by a podiatrist.

iHealth lends additional support in this regard, reviewing any claim line set to “Pay” for billing

appropriateness by specialty. QNXT™ checks other provider-specific items as well, verifying,

for example, that each provider has obtained the requisite National Provider Identifier (NPI) or

its equivalent, and has included it on all claims submissions.

Member Eligibility and Enrollment

QNXT™ validates the date of service against members’ enrollment segments to determine their

eligibility on the date of service. If a member was ineligible on the date of service, the system

will automatically deny the claim using the appropriate HIPAA-approved remittance comment.

Duplicate Billing Logic

QNXT™ uses a robust set of edits to determine duplication of services. Examples include same

member, date, network provider, service or any combination of these criteria. In addition, claim

lines set to “Pay” are subjected to iHealth’s duplicate logic. That will protect MMIC from

paying for services rendered by the same physician or other physicians within the same provider

group.

ClaimCheck® Edits

ClaimCheck® is a comprehensive code auditing solution that supports QNXT™ by applying

expert industry edits from a provider-recognized knowledge base to analyze claims for accuracy



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and consistency with MMIC’s P&Ps. ClaimCheck clinical editing software identifies coding

errors in the following categories:

Procedure unbundling

Mutually exclusive procedures

Incidental procedures

Medical visits, same date of service

Bilateral and duplicate procedures

Pre- and post-operative care

Assistant surgeon

Modifier auditing

Medically unlikely

MMIC will offer network providers access to Clear Claim Connection®, a reference tool that

helps them optimize their claims submission accuracy. Currently there are 2,300 provider

groups registered to use this web-based tool. Providers can use it to explain MMIC's clinical

editing logic, allowing them to better understand the rules and clinical rationale affecting

adjudication. Providers will access Clear Claim Connection® through our web portal via secure

login. They can then enter various coding combinations to determine why, for example, a

particular one resulted in a denial. The provider may also review coding combinations prior to

claim submission, to determine whether applicable auditing rules and clinical rationale will deny

the claim. Figures 2 & 3 on the following page are screen shots of the Clear Claim Connection

access portal.



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Figure 2: Clear Claim Connection Claim Audit Results

Figure 3: Clear Claim Connection Edit Clarification



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iHealth Edits

iHealth will clinically edit claims to assist MMIC to promote the proper, fair payment of

professional DME and outpatient claims.

Coding Accuracy

If services are up-coded, or unbundled, iHealth will alert the Claims Department to deny the

claim line, along with the specific clinical editing policy justification for the denial. The claim

line denial will include the appropriate HIPAA remittance remark on the Explanation of Benefits

(EOB).

Duplicate Billing Logic

In addition, claim lines set to “Pay” are subjected to iHealth’s duplicate logic. It will protect

MMIC from paying for services rendered by the same physician or other physicians within the

same provider group.

Durable Medical Equipment (DME) Editing

iHealth performs edits related to select DME payment policies aligned with covered service

policies. These edits include DME rentals, oxygen and oxygen systems, hospital beds and

accessories, external infusion pumps and anatomic/functional modifiers required for services.

Procedure Code Guidelines - iHealth

MMIC will follow the AMA CPT-4 Book and CMS HCPCS Book, which both provide

instructions regarding code usage. iHealth has developed these guidelines into edits. For

example, if a chemotherapy administration code is billed without the correct pharmacy codes,

MMIC would deny the code as inappropriate, based on industry standards.

Procedure Code Definition Policies - iHealth

iHealth supports correct coding initiatives based on the definition or nature of a procedure code

or combination of procedure codes. These editing policies will either bundle or re-code

procedures based on the appropriateness of code selection. For example, if a provider attempts



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to unbundle procedures, iHealth will apply editing logic that will bundle all of the procedures

billed into the most appropriate code.

MMIC will also use the MDE OPFS pricer to edit outpatient facility claims and apply AHCCCS

edits for bundling, modifier code use, and other scenarios according to the OPFS decision tree.

Fraud and Abuse

MMIC’s Fraud and Abuse Department, under the direction of the COO, will utilize claims

payment tracking and trending reports, claims edits, audits and provider billing patterns as

indicators of potential fraud and abuse. The Fraud and Abuse department will use this

information to detect aberrant provider billing behavior, which will prompt additional analysis

and investigation. Our fraud and abuse personnel will work in conjunction with Provider

Services and Compliance departments to address any questionable behavior(s) through provider

education and outreach. If MMIC discovers, or becomes aware, that an incident of

potential/suspected fraud and abuse has occurred, internal P&Ps will mandate that we report the

incident to AHCCCS within ten (10) business days by submitting the confidential AHCCCS

Referral for Preliminary Investigation form.

Claims Education

MMIC’s Provider Claims Educator will work to educate providers on appropriate claims

submission requirements, coding updates and available resources, such as Provider Manuals,

websites and fee schedules. In addition, the Provider Claims Educator will participate in an

AHCCCS work group tasked with developing uniform guidelines for standardizing hospital

outpatient and outpatient claim requirements, sharing information accordingly.

Claims Editing Results

In the first three quarters of 2012, through its robust and comprehensive claims editing programs,

Schaller cost-avoided/recovered in excess of $30 million related to the ALTCS program.



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Claim Edits $

1st Quarter $7,123,919

2nd Quarter $9,860,388

3rd Quarter $13,173,557

4th Quarter

Total: $30,157,864

MMIC key IT staff will review all strategies for implementing its management information

system, claims and encounter processing and other systems that rely on data or data processing to

achieve full compliance with all contractual obligations. They will coordinate our efforts to

collect, analyze, integrate and reports data.

Please see Figure 4 on the following page for an example of the Claims Data Dashboard MMIC

will use to track, trend and monitor claims activity.

Additionally, please see the Attachments Tab of ProcureAZ for further examples of the Claims

Data Dashboard MMIC will use to track, trend, and monitor claims activity:



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Figure 4: MMIC Claims Data Dashboard



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17.16 General Claims Processing Requirements When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:

Mercy Maricopa Integrated Care (MMIC) recognizes the need to provide a seamless, integrated

claims processing function across the organization, while managing the process for maximum

efficiency, visibility and flexibility with our dynamic claims processing approach.

MMIC’s key Information Technology staff will review all strategies for implementing its

management information, claims, encounter processing and other systems that rely on data or

data processing to achieve full compliance with all contractual obligations. These staff will

coordinate MMIC’s efforts to collect, analyze, integrate and report data. MMIC’s IT staff will

utilize the following documents during implementation:





During the initial implementation process, MMIC will have an audit plan in place to monitor the

transition. Upon completion of implementation, we will audit 100 percent of all benefits for

correctness to ascertain no forward issues with the processing system. We will comply with all

data submission standards required by this contract, and will work to make timely corrections to

any data files rejected by ADHS/DBHS.

17.16.1 Claim Processing Requirements and the Balanced Budget Act of 1997

MMIC will base all of our claims processes on the Claim Processing Requirements defined by

the Balanced Budget Act of 1997 and 42 CFR 447.45. We will adhere to all requirements

related to:



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Timely processing of claims for payment

Prepayment and post-payment claims reviews

Our internal policies and procedures will define a claim as:

A bill for services

A line item of service

All services for one recipient within a bill

A clean claim is one that can be processed without obtaining additional information from the

service provider or a third party. It includes a claim with errors originating in a state’s system. It

does not include a claim from a provider who is under investigation for fraud or abuse, or a claim

under review for medical necessity.

17.16.2 Staff Training on HIPAA Requirements For Electronic Payment/Advice 835

Transaction

MMIC’s Medicaid Core Skills training will be designed to equip our claims specialists to process

claims accurately and efficiently. This 12-week training course will be delivered through a

tiered approach following New Hire Training, which addresses basic HIPAA requirements. The

course will specifically introduce staff to each type of claim and its processing, and the ability to

audit the results for training purposes. This course will also cover HIPAA requirements for

electronic Health Care Claim Payment/Advice 835 transactions.

Staff training will build on a foundation that includes topical knowledge of MMIC, regulatory

compliance requirements, and business practices relating to claims. Our staff training includes

the following components:

A complete review of the state’s submission and data demographic requirements



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The next level of training will include knowledge of specific claims processing procedures

for authorizations, review of benefit and contract descriptions, member eligibility, claim

check edit resolution, re-submissions, coordinating benefits, claim form validation against

QNXT, and review of provider-submitted documentation. This phase will emphasizes the

appropriate resources and tools for accurate and timely claims processing.

Plan-specific training comprises the final phase, building on knowledge obtained during the

Core Skills program. It will examine specific topics and procedures for the selected plan.

At the completion of each phase of training, each staff must achieve successful error rate testing

scores. Each participant must achieve a minimum score of 85 percent to achieve certification of

training completion. We will also implement a core skills assessment as a level two assessment

throughout the training period, measuring comprehension and application of procedures. In

addition to training our staff, MMIC will offer the same claims processing training to our

providers and will maintain documentation of the training in the provider’s credentialing file.

17.16.3 Post Claims Inquiry Information to Providers on Website

MMIC will maintain a separate provider module on its website for viewing claims status.

Providers will receive detailed instructions on accessing the claims query module during

orientation, and will be informed of any updates to the system through provider site visits,

Newsletters, and updates to the Provider Manual.



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17.16.4 Claims Submission Deadlines

17.16.14 Recoup of Funds from a Provider After Twelve Months from Original Payment

17.16.15 Provider Reimbursement for Recouped Funds

17.16.16 Providers to Submit a New Claim Within 90 Days

17.16.17 Processing the Provider’s Claim

17.16.18 Providers Have 90 Days to Submit a Clean Claim for Payment

17.16.19 Not Deny Claims Submitted as a Result of a Final Agency Decision

As previously stated, Mercy Maricopa Integrated Care (MMIC) will follow the set guidance of

the Balanced Budget Act of 1997 and 42 CFR 447.45. Our claims processing policies and

procedures detail our response to individual situations and direct our claims adjudicators on the

following:

Not recoup funds from a provider more than twelve months after the date of original payment

on a clean claim without prior approval of ADHS/DBHS, in conformance with the its Office

of Program Support Operations and Procedures Manual and the AHCCCS Contractor

Operations Manual Claims Reprocessing Policy

Reimburse providers for recouped funds if the provider was subsequently denied payment by

the primary insurer based on timely filing limits or lack of prior authorization, and the

member failed initially to disclose coverage other than Medicaid, when the provider made an

initial timely claim to MMIC

Require a provider to have ninety days to submit a new claim and documentation from the

primary insurer that payment will not be made. Documentation that MMIC will accept

includes any of the following items establishing that the primary insurer has or would deny

payment based on timely filing limits or lack of prior authorization:

An EOB



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Policy or procedure

The MMIC Provider Manual excerpt

Process the provider’s claim consistent with applicable statutes, rules, policies and contract

terms when a final agency decision is made to deny, limit or delay authorization of services,

and the member received the disputed services while an appeal was pending

Require the provider to have ninety days from the date of the final agency decision to submit

a clean claim for payment, and not deny it as untimely if submitted within that time frame

Not deny claims submitted as a result of a final agency decision because the member failed to

request continuation of services during the appeals/hearing process

Unless a shorter time period is specified in contract, not pay a claim initially submitted more

than six months after date of service, or a clean claim submitted more than twelve months

after date of service, except as directed by ADHS/DBHS, or otherwise noted in this contract

MMIC’s claims processing policies and procedures will stipulate that claim payment

requirements will apply to both contracted and non-contracted providers. Claims will be tracked

in our system as follows:

The receipt date of the claim is its date stamp, or the date it was electronically received.

The receipt date is the day the claim is received at the contractor’s specified mailing address.

The paid date of the claim is the date on the check or other form of payment.

Submission deadlines are calculated from the claim end date or the effective date of

eligibility posting, whichever is later.

The filing limit is configured within QNXT, and claims received more than six months from

the last date of service, as indicated on the claim, will be automatically denied, unless

submitted as a reconsideration or with specific direction by AHCCCS.



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17.16.5 Adjudication of Clean Claims Within 30 Days of Receipt

MMIC’s processing guidelines will require providers to submit all claims no later than 12

months from the date of service. When timely submissions are received:

MMIC will pay 95 percent of all clean claims from providers in individual or group practice

or who practice in shared health facilities within 30 days of receipt.

MMIC will pay 99 percent of all clean claims from providers in individual or group practice

or who practice in shared health facilities within 60 days of receipt.

MMIC will pay all other claims within 12 months of receipt, except in the following

circumstances:

Retroactive adjustments paid to providers who are reimbursed under a retrospective

payment system

If a claim for payment under Medicare has been filed in a timely manner, MMIC will pay

a Medicaid claim relating to the same services within six months after the agency or the

provider receives notice of the disposition of the Medicare claim.

The time limitation does not apply to claims from providers under investigation for fraud

or abuse.

Additionally, MMIC will conduct prepayment review for all claims based on the following

criteria:

Verification that the recipient was included in the eligibility file and that the provider was

authorized to furnish the service at the time.

Checking that the number of visits and services delivered are logically consistent with the

recipient’s characteristics and circumstances, such as type of illness, age, sex and service

location



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Verification that the claim does not duplicate or conflict with one reviewed previously or

currently being reviewed

Verification that a payment does not exceed any reimbursement rates or limits

Checking for third party liability within the requirements of § 433.137

Finally, MMIC will conduct post-payment claims review utilizing our state-of-the-art analytic

software that meets the requirements of parts 455 and 456 of42 CFR 447.45.

17.16.6 Reimbursement for In-State and Out-Of-State Non-Contracted Emergency

Services at the AHCCCS Fee-For-Service Rate

17.16.7 Reimbursement for Non-Contracted, Non-Emergency In-State Providers

MMIC’s internal claims procedures and Provider Manual information will address

reimbursement rates for both in- and out-of-state non-contracted emergency services providers.

We will reimburse these entities at no more than the AHCCCS Fee-For-Service rate in

conformance with the Deficit Reduction Act of 2005, Section 6085. If there is no written

negotiated rate for the particular service rendered, MMIC will reimburse non-contracted, non-

emergency, in-state providers according to the AHCCCS fee schedule and methodology, or

pursuant to A.R.S. §36-2905.01, at ninety-five percent of AHCCCS FFS rates for urban hospital

days in conformance with A.R.S. §§36-2903 and 36-2904. All payments will be subject to other

limitations, such as provider registration, prior authorization, medical necessity and covered

service.

Our claims processing flow is outlined in Figure 1 on the following page.



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Figure 1: MMIC’s Claims Process Flow

17.16.8 Interest on Late Payments for All Non-Hospital Clean Claims

MMIC’s claims processing policies and procedures will direct our claims adjudicators to pay

interest on late payments for all non-hospital clean claims, unless there is a contract specifying

other terms. We will define late payments as those paid more than forty-five days after receipt of

a clean claim. Interest payments will be calculated systematically for the difference, in days,

from the clean date entered on the claim and the check date (interest days).

For non-hospital (participating and non-participating) unadjusted claims, MMIC will pay interest

on clean claims if the payment is not made within 45 calendar days of receipt (calculated clean



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claim date through check date), using a flat rate of 10 percent per annum as determined by the

Arizona Health Care Cost Containment System (AHCCCS), and highlighted in the Contractor

Operations Manual. The interest period will begin the day after payment is due and end on the

date of payment. It will be calculated using the following formula: payment amount x interest

rate x interest days divided by 365.

In grievance situations, or when a claim is adjusted through the reconsideration process, MMIC

policy will direct that interest may be paid retroactively to the date it would have started to

accrue at the rate of ten per cent (10%) per annum – unless a different rate is specified in the

contract – if it was determined that the claim was not paid appropriately based on initial available

information. In the absence of terms in a subcontract, interest will accrue starting on the first day

after a clean claim is contracted to be paid. MMIC will apply interest on adjustments to payment

amounts in excess of the original payment (for instance, if the claim underpaid by $25, interest

would only be applied to the $25 adjustment) for any claim where the clean date on the adjusted

claim is the same as the original claim. Any interest applied to the original claim will be added

in to the second payment. If the clean date for the adjusted claim is different from the original,

we will calculate interest the same as an unadjusted claim for the full amount of the payment.

MMIC will document specific guidelines for appropriate application of the clean date for

adjusted claims in the Claims Desktop.

17.16.9 Slow Payment Penalty for Hospital Clean Claims

When a hospital clean claim is pended or delayed for any reason, causing MMIC to fall into a late

payment situation, we will pay a slow payment penalty in conformance with A.R.S. § 36-2903.01.

Our data management system will be configured to pay interest automatically, based on days over

the late payment threshold according to the date the claim was received and the date payment was

made. Interest penalties will be based on a 30-day calendar month, starting at 1 percent for the first



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month and increasing by 1 percent each successive month. Claims paid within 61-90 days of clean

claim date will accrue a 1 percent interest penalty, 91-120 days a 2 percent penalty, and so forth.

17.16.10 Report Interest Paid

17.16.11 Minimize Likelihood of Recouping Funds from Paid Claims

17.16.12 Individual Recoupment in Excess of $50,000 Per Provider Within a Contract Year

17.16.13 Cumulative Recoupment Greater than $50,000 Per Provider Tax Identification

Number Per Contract Year

To minimize the likelihood of recouping funds from paid claims, MMIC expects its payment

processes to remunerate on time for clean claims received within established time frames. We

will report any interest paid for late payment in conformance with the AHCCCS Encounter

Manual. It will be our standard practice to always obtain the prior approval of ADHS/DBHS for

any individual recoupment in excess of $50,000 per provider within a contract year. We will

also notify ADHS/DBHS of any cumulative recoupment greater than $50,000 per provider Tax

Identification Number per contract year. We will monitor weekly payment reports to verify

compliance with the requirement.

MMIC’s dynamic claims processing approach will standardize our processes and improve the

flow of information from claims to all other departments, thereby enhancing our agility and

responsiveness to changing conditions. By improving traditionally static, disconnected and

inflexible claims processes, we will accurately identify, manage and reduce risk exposure;

improve member service; gain operational efficiency, and adapt to change more quickly and

easily.



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17.17 Claims System Reporting When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:

Mercy Maricopa Integrated Care (MMIC)’s will manage the claims reporting process efficiently,

aligning it with business objectives, and achieving real-time operational awareness.

Modernizing the process for efficiency and flexibility will be a mission-critical function that

touches all parts of the organization, affecting member service, fraud and abuse management,

risk exposure, cost control, and Information Technology (IT) infrastructure.

Our key IT staff will review all strategies for implementing the management information system,


achieve full compliance with all contractual obligations. They will coordinate MMIC’s efforts to

collect, analyze, integrate and report data. MMIC’s IT staff will utilize the following documents

to assist in implementation activities:





MMIC will also comply with all data submission standards required by this contract and accept

ADHS/DBHS rejection of data submissions not in compliance.

17.17.1 Monthly Claims Dashboard

MMIC will submit a monthly Claims Dashboard to ADHS/DBHS, in conformance with the

AHCCCS Claims Dashboard Reporting Guide, which includes the Cost Avoidance/Savings/

Recoveries Report, as specified in the Office of Program Support Operations and Procedures



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Manual, the AHCCCS Program Integrity Reporting Guide, and the Number of Claims and

Amounts Paid Report.

MMIC will be responsible for paying claims. We will develop an internal Claims Dashboard to

conform to the AHCCCS Claims Dashboard Reporting Guide, edition revised October 2010.

Following the guidance of the AHCCCS Claims Dashboard Reporting Guide, we will submit the

Cost Avoidance/Savings/ Recoveries Report and the Number of Claims and Amounts Paid

Report as directed by the ADHS/DBHS Office of Program Support Operations and Procedures

Manual, and the AHCCCS Program Integrity Reporting Guide.

Each MMIC dashboard will be dedicated to one line of business. The dashboard(s), along with

all attachments, will be sent to the Contractor’s Acute Operations and Compliance Officer

(ACO) via email. If hard copies are requested, MMIC will send them to the appropriate ACO at:

AHCCCS Division of Health Care Management (DHCM)

701 E. Jefferson, MD 6500

Phoenix, Arizona 85034

MMIC is prepared to submit a separate Claims Dashboard for each of the following claim form

types:

UB92 or 837I

CMS1500 or 837P and, Dental Claim Form or 837D combined

All claim form types combined

The following items will be included in the dashboard(s) as of the last day of the reporting

month:

Claims inventory

Days of work on hand

Percentage of pended claims



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Number of pended claims

Number of medical review pended claims

Per guidance from the AHCCCS Claims Dashboard Reporting Guide, the MMIC Finance and

Health Plan Operations departments will highlight and explain the variance for each area that is

out of compliance with contracted standards, areas where there is a five percent increase from the

previous report in the number of denied and/or pended claims, areas where claims receipts have

decreased by more than five percent, areas where average time to process claims has increased

by more than five days, and areas where total claims processed have decreased by five percent.

Additionally, MMIC will report on the Total Claims Dashboard Template the percent of claims

paid correctly for the reporting period as determined from our internal audit procedures, and the

total amount of advances paid to providers in the reporting period.

We understand that ADHS/DBHS may request that we review claim requirements, including

billing rules and documentation requirements, and submit a report to them in an approved format

that includes the rationale for the requirements. Our Finance department will be designated as

the internal asset to review claims requirements and prepare reports for submission to

ADHS/DBHS.

MMIC will pull dashboard(s) information from its reporting system. Our dashboards will be

designed to track claims processes and enable accurate, timely and complete payments. Please

see Table 1 below and continuing on the following pages for details regarding the three standard

claims management reports to supply dashboard(s) data:



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Table 1: Three Standard Claims Management Reports Report Name

Description Accuracy/ Measurement

Claims Dashboard

Tracking of claims processes including: Membership Total Claims Receipts % Paper Claims % Electronic % Paid ETF % Remittances via 835 Total Inventory Average Days Receipts; Days of Work on Hand; Total number of Claims Pended Claims pended for Medical Review Total Claims Denied % Denied Dollars denied Average Time to process all Claims Total claims processed EOM Total amount of advances paid Total Medical Claims Liability IBNR

Reports the percentage of clean claims paid claims that fall within the following categories: 0 – 30 days old 31 to 45 days old 46 to 60 days old 61 + days old % Pended not paid in 30 days # Pended 61+ Days Average age of claims’ pended for medical review % of claims processes within contracted deadline % of Claims Processed in 0 to 30 days % of Claims processes in 60 days EDI auto-processing rate

Pend Summary

Claims processes tracked: Received Type Billed_5K_25K_50K Pay to PAR NON PAR Contract Form Type Program Description Specialty As Of Date Department Name and Reason Category Count of Claim ID Category Sum of Total Billed

Report of claims payment managed through the following pend types: B01 – DRG/Microdyn Updates B02 – Service code updates B03 – Fee schedule updates B05- Implementation/Benefit Research B06 – Implementation/Contract Research C00 – NO REASON C01 – Enrollment Restriction Required C02 – COB Review C05 – Benefit/Contract flagged for Manual Review C06 – Provider research C07 – Data Entry – Keying Research for missing claim information C10 – System Configuration Review C11 – Claim for required documentation review C12 – Auth Review C13 – FIFO returned manual pends



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Report Name


C17 – Claims Supervisor Review C19 – Enrollment restriction review C20 – Broken OB package review C21 – DRG Review C23 – Transplants C25 – HCBS Room & Board review C27 – Invalid Revenue Code C29 – Invalid POA indicator or diagnosis code when diagnosis requires POA indicator C30 – High dollar claims C31 – CI/CR-COB Supervisor Review C33 – SNP Medicare COB C35 – Return From Medplans C36 – LTCH/IPF/ORF Manual pricing C37 – PPOS/RUGS pricing review C38 – OPFS Pricing failure C46 – H, S, T Codes C47 – SNF – Acute C48 – CMS Manual Pricing C54 – EDI Provider Not Found C55 – EDI Pay to Issues C56 – Edit 201 w/ Unknown EDI or FV C57 – Age/Gender Conflict C58 – Line DOS spans timely filing C59 – Auto adjust / re-import claim pends C60 – CC & Project returned manual pends C61 – CICR COB pends C62 – Claims Support Assistant – Void Claim C64 – OPFS Rejects C66 – LOA C68 – Split Claims/Eligibility C69 – McKesson Claim Check C70 – Re-submissions C71 – FV over 999 units C72 – FV anesthesia unit review C73 – FV Provider selection review C74 – FV Pay to Issue C75 – FV – Member enrollment review C76 – FV Member Unknown C77 – FV Incomplete provider information C78 – FV – DOS review



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Report Name


C79 – FV – Bill type review C80 – FV CPT code review C86 – Future Vision-Provider Not Registered with AHCCCS C94 – Provider Preventable Conditions C97 – Split claims for annual rate changes Accuracy of training is also managed through the use of the following Claims QR Training Pend Codes: E02 – Analyst Review (QR) E04 – Claims Analyst Rebuttal E13 – Massa Adj E14 – Med Plans Adj E07 – CICR Review (QU) E22 – Encounter Correction-Mercy Care H01 – Provider Services for provider contract add H02 – Provider Watch H03 – Member Solutions/Eligibility update H04 – Prior Authorization/Medical Management review H05 – Retro review for inpatient claims H07 – Medical review for HCAC H08 – Medical review for Reconsiderations H25 – HCBS Room & Board review H31 – Pending provider system changes H98 – HPO research for reconsiderations H99 – Health plan review for manual payments L01 – Medicare development call L02 – Medicare – 2nd development call L03 – Medicare – Final development call L04 – Medicare development pending provider response L05 – Medicare – development letter required L09 – Holding for development – letter sent M01 – Medical review of outlier payment M02 – Medical review for payment of PPC P01 – Provider record review required P05 – Provider record pay to update P06 – Provider record affiliation update



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Report Name


P07 – Provider record not found P09 – Provider ID needed for Microdyn pricer P14 – Rendering provider name mismatch P15 – Provider not active on DOS P23 – Provider transplant pends S01 – Special investigation claim review S02 – Special investigation payment hold

Non-Final Manages timeliness and completeness of Claims Adjudication processes by tracking the number of claims pended or otherwise not finalized and the age categories of all the reason codes described in the Pend Summary Report above.

Age categories are tracked as follows: 0-5 06-10 11-15 16-20 21+

17.17.2 Review Claim Requirements and Submit a Report to ADHS/DBHS

In compliance with the requirements in the AHCCCS Claims Dashboard Reporting Guide,

MMIC will supply the following information on a monthly basis:

Top five reasons for claim denials and how many claims were denied during the reporting

period for each reason

The five providers with the greatest number of claims denials, including how many for each

provider

All providers for which MMIC is working on a special claims processing or claims review

project including the following information:

Reason for project

How many claims are affected

Stratify claim count by age of claim (0-30 days, 31-60 days, etc.) using each of the

following:

Date of receipt



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Start of project date

MMIC’s commitment to the accuracy of claims reporting will be a cultural dynamic integrated

into every facet of our organization. We will take reporting seriously, and will comply with all

data submission standards required by this Contract.

Please see the Attachments Tab of ProcureAZ for examples of our Claims Dashboard reports.

17.18 Claims Audits Offeror Response:

Mercy Maricopa Integrated Care (MMIC), through its sponsors Mercy Care Plan (MCP) and

Maricopa Integrated Health Systems (MIHS), will offer a unique audit and control approach.

Our comprehensive approach will be based upon linking rigorous audit systems and procedures

together to identify possible claims processing deficiencies. Our approach will seek not only to

identify errors and recoveries, but more importantly to reveal, prioritize and remedy their

underlying causes.

Our key Information Systems (IS) staff will review all strategies for implementing the

management information system, claims and encounter processing, as well as other systems that

rely on data or data processing to achieve full compliance with all contractual obligations. They

will coordinate MMIC’s efforts to collect, analyze, integrate and report data and will utilize the

following documents to assist in implementation activities:







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Additionally, MMIC will comply with all data submission standards required by this contract

and accept ADHS/DBHS rejection of any data submissions that are not in compliance. We will

then work to make timely corrections to the file for re-submission.

17.18.1 Internal Claims Audit Function That Will Include the Following

17.18.1.1 Verify that Provider Contracts are Loaded Correctly 17.18.1.2 Verify Accuracy of Payments Against Provider Contract Terms

MMIC will be responsible for paying claims. Through its sponsor, MCP, we will have robust

internal claims auditing process to establish accuracy and compliance with established policies,

procedures, management service agreements and contracts. This process will be the pivot point

for all MMIC functions related to internal claims auditing, and will be managed by the Claims

Audit department. The process will be designed to verify accuracy of contracts and payments,

perform necessary audit functions, document audit findings, and prepare audit finding

submissions for regulatory agencies.



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17.18.2 Audits of Provider Contract Terms

17.18.4 Document the Findings of Audits and Initiate Corrective Action for Deficiencies

MMIC’s Claims Audit Services team will conduct audits. The team will comprise experienced

auditors and management team that comply with Sarbanes Oxley standards to meet specific

controls. We will use MCP’s audit standards, which exceed the requirements, as demonstrated

by random, statistically valid audits with a 95 percent confidence level, two percent expected

error rate and a plus/minus two percent confidence level.

All audits will validate system configuration for plan, contract and benefit structures, and claim

adjudication and processing for each claim reviewed. We will review claim entry from images

pulled from Alchemy or from EDI data submitted. MMIC will share all results by e-mail

notification, post audit files on a SharePoint site and track the results in an internal database.

Audit Purpose and Objectives

The following represent MMIC’s audit purposes and objectives:

Audit adjudicated claims and system configuration to maintain accuracy and compliance

with established policies, procedures, management service agreements and contracts.

Analysis using independent source documentation to identify root cause

Timely identification, communication and resolution of identified issues

Provide independent assessment and accuracy rates for claim population

Audit files distributed to the Health Plan and all impacted departments

Identify potential provider billing issues and report them to the respective Health Plan’s

Compliance Officer

Generate reports of audit files and results monthly and quarterly, and utilize them to track

open audits, trend claims processes, and identify system configuration accuracy and

efficiency.



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Frequency of Audits

The frequency of claim, contract or benefit audits will depend on the number of members,

complexity of services, frequency of changes to the operational system, or regulatory

requirements. The Claims Audit Services department will conduct at least two statistically valid

claim audits per month per form type.

Claim Audit Process:

1. Validate the contractual appropriateness of the provider attachment to the contract and fee

schedules.

Audit Process - Provider Validation: All PAR providers must have a signed contract that is

accessible for use by the Claims Audit department. It will validate the contractual

appropriateness of the provider attachment to source documentation, and report any

discrepancies to the Health Plan and the Network Development department and track on the

audit file. (SOX Control – 1A)

2. Filter the contract to review the different contract types individually for proper application of

reimbursement methodologies and calculations.

Audit Process - Contract Validation: All PAR contracts will be accessible for use by the

Audit department. It will validate contract system configuration for payment appropriateness

to the source documentation, report any discrepancies to the Business Applications

Management department, and track the audit file. Each claim line will be analyzed for

appropriateness of contract term selection during the audit process. (SOX Control – 1B)

3. Filter to review the benefit and identify various reimbursement methodologies to apply

correct payment calculations and identify specific requirements, such as PA, accumulators,

age limitations, exclusions, co-pays, deductibles and coinsurance.

Audit Process - Benefit Validation: Benefits will be validated using Summary Plan

Documents (SPD) and/or Explanation of Coverage (EOC) and/or the Health Plan Medicare



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Summary of Benefits (SOB), which will be accessible for use by the Audit department. We

will validate benefit system configuration for payment appropriateness to source

documentation, report any discrepancies to the health plan and the Business Applications

Management department, and track the audit file. Each claim line will be analyzed for

appropriateness of the benefit term selection during the audit process. (SOX Control – 1C)

4. Audit Process - Claim Validation: Complete form data field validation through viewing the

paper claim submitted via Alchemy or viewing EDI data submitted. All claims will be

subjected to analysis that includes valid coding, timely filing, prior authorization

requirements, benefit application (including limitations and exclusions), coordination of

benefits application, claim history review for duplicate claims, manual pricing application,

special provider agreements, modifier discounts, and claims bundling/unbundling. (SOX

Control – 1D)

In addition to the standard audits identified above, as provider contracts and new/existing

contract/benefit changes are implemented, we will audit all impacted terms for a high-level

review of the following:

Contract Terms

General Information

Payment

Location

A very high level review may or may not be done for Services, ICD9, Procedures and

Service Groups

Benefit Terms

General Information

Services

Co-pay



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Restrictions

Limits

A very high level review may or may not be done for ICD9, Procedures and Service Groups

17.18.3 Audit Sampling Methodology

If no changes are made to a provider’s contract, MMIC will audit the provider at least every five

years based on a random sampling of ten percent of the claims submitted by the provider for the

review period. At the conclusion of scheduled or ad hoc audits, the Claims Audit department will

be responsible for documenting the findings and initiating corrective action for deficiencies.

Providers who do not achieve acceptable rates of compliance may be subject to more frequent

audits until they achieve compliance.

17.18.5 Independent Audit of its Claims Payment/Management Information System

17.18.6 Scope of an Audit

MMIC recognizes the value of a true cooperative relationship with ADHS/DBHS, and welcomes

the opportunity to collaborate to expand the scope of our internal claims audit processes to

include areas such as a verification of eligibility and enrollment information loading, contract

information management (contract loading and auditing), claims processing and encounter

submission processes. In the event of a system change or update, or when directed by

ADHS/DBHS, MMIC will cooperate with an independent audit of its Claims

Payment/Management Information System.



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17.18.7 Submit Audit Findings to ADHS/DBHS

As contractually required, MMIC will submit audit findings to ADHS/DBHS. Additionally, we

will submit audit findings performed by other external entities when completed.

Per our sponsor Mercy Care Plan (MCP)’s current internal policies and procedures, the MMIC

Claims Audit department will perform four statistically valid audits each for Medicaid and

Medicare claims each month. They will consist of two monitoring audits per two week period

for each form type. Claims types include both medical and behavioral health. As with MCP, our

overall percentage of claims audited are expected to reflect ninety-five percent confidence, with

an error rate of two percent, and a desired precision of plus/minus two percent. An example of

MCP’s audit process follows.

Auditing was performed in April of 2012 with the objectives of:


Independent assessment and accuracy rates for claim population

Audit of adjudicated claims and QNXT system configuration to maintain accuracy and

compliance with established policies, procedures, management service agreements and

contracts

Reports of audit results used to improve claims processing and system configuration

accuracy and efficiency

Eight random, statistically valid standard audits when “paid/denied” status is completed

within a live environment:

Four – UB04

Four – CMS 1500



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MCP’s most recent audits have resulted in the following results that confirm the accuracy of its

provider and contract validation processes:

Provider validation overall accuracy: 99.8 percent

Through this process, MCP was able to identify two issues relative to provider validation, as

illustrated in Table 1 on the following page:



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Table 1: Issues Relative to Provider Validation

Rank Issue # Lines% of

Contract Issues

Comments

1 Contracting – Contract Needed 22 68.75% Missing copy of contract to validate Par provider for SOX Compliance.

2 Provider – Contracts 10 31.25% Review provider contract attached.

Total 32 100%

Contract validation overall accuracy: 100 percent

Contract validation issue detail – top issue: N/A

Utilizing MCP’s internal claims auditing process, MMIC expects to be able to review benefit

validation using the Summary Plan Documents (SPD), the Explanation of Coverage (EOC), and

the Health Plan Medicare Summary of Benefits (SOB) – all provided through the Claims Audit

department. MCP assesses each claim line to evaluate the appropriateness of the benefit term

selection. It also reviews the documents listed above to validate system configuration and

confirm the appropriateness of source documentation. When discrepancies are found, MCP

reports them to the Health Plan and Business Applications Management department for review

and action.

Recent findings for the third quarter of 2012 are as follows:

Benefit validation overall accuracy – one hundred percent (100%)

Benefit validation issue detail – top issue: N/A

Additionally, MCP monitors the claim validation process by examining data fields for each

claim, viewing paper claims submitted through Alchemy or EDI data. It reviews all claims for

valid coding, timely filing, prior authorization requirements, benefit application (including

limitations and exclusions), coordination of benefits application, claims history review for

duplicates, manual pricing application, “Special Provision” provider agreements, modifier

discounts and claims bundling/unbundling. Recent findings for 3Q 2012 are as follows:



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Claim validation overall accuracy – 99.29 percent

Through this process we were able to identify two issues relative to claim validation, as

illustrated in Table 2 below:

Table 2: Issues Relative to Claim Validation

Rank Issue # Lines% of

Claim Issues

Comments

1 Claims - Processing 109 97.32% Various manual processing issues

2 Claims - Memo 3 2.68% Claim memo missing information or inappropriate.

Total 112 100%

2012 3rd Quarter Claims Audit Summary Report

MCP conducted a total of eight standard audits on claims with the status of “paid/denied,” based

on a random, statistically valid sample within a live environment. The objectives of these audits

included:


Independent assessment and accuracy rates for claim population

Audit of adjudicated claims and QNXT™ system configuration to maintain accuracy and

compliance with established policies, procedures, management service agreements and

contracts

Reports of audit results to improve claims processing and system configuration accuracy and

efficiency

Recent findings are illustrated in Table 3 on the following page:



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Table 3: Quarterly Summary of Standard Claim Audit Findings

Month 2012

Number of Audits Distributed

Number of Claims Audited

Number of Claim Lines

Audited

Payment Accuracy

Financial Accuracy

July 4 745 7321 99.87% 99.98%

August 2 373 4129 98.39% 96.62%

September 2 373 4367 99.20% 99.93%

3rd Qtr. Total

8 1491 15817 99.33% 99.27%

To guarantee transparency in the claims process, and facilitate accuracy and timeliness, MCP

conducts additional audits that provide supplementary statistical information for management

reports. Those reports include:

Summary of findings for standard audits

Target audits

Issues identified

Monthly top 5 issues report

Procedural issue detail – Top 5 issues, the spotlight and actions resulting from findings

Systematic issue detail – Top 5 issues, the spotlight and actions resulting from findings

Outstanding claims audits

Claims audits closed during the month (TAT- turnaround time to close an audit)

Quarterly summary of standard claim audit findings

Quarterly summary of target claim audit findings

Quarterly aging summary

Quarterly key issues identified

As a visual report example, a combined “Summary of All Audit Findings” is presented in the

format illustrated in Figures 1 and 2 on the following page.



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Figure 1: Key Controls Measures for SOX – 3rd Quarter 2012 MCP

Figure 2: SOX Key Issues – 1st Quarter 2011 MCRP-MCA



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MMIC is keenly aware of the constantly changing technical environment that drives claims

management, and will maintain cutting-edge auditing processes to keep abreast of new

technology. Therefore, when changes are made or systems are updated, we will fully participate

and cooperate with any independent external audit of our Claims Payment/Management

Information System as requested by ADHS/DBHS or any other regulatory agency.

Our Claims Audit department will be accountable for preparing submissions of claims auditing

findings, and submitting them directly to ADHS/DBHS or any other regulatory agency requiring

this information. MMIC will follow submission formats as specified contractually by

ADHS/DBHS.

MMIC’s ability to control claims expenses through a streamlined audit process will have a

dramatically positive impact while providing new and unique differentiating flexibility in

processing. That flexibility will enable MMIC to innovate and react quickly to unpredictable

events creating a system that provides effective health care and enhanced member satisfaction.

17.19 Demographic Data Submission When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:

Mercy Maricopa Integrated Care (MMIC) understands the importance of demographic data and

timely submission. MMIC’s sponsor agency, Mercy Care Plan (MCP), serves over 340,000

Medicaid, Medicare Advantage Special Needs Plan and developmentally disabled members.

With experience collecting demographic data as required by AHCCCS Medical Policy Manual

940.1, MCP brings expertise that MMIC will use in order to provide the data necessary to

support the RBHA system.



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17.19.1 Submit Behavioral Health Member Demographic Data

MMIC will use the Better Health Enterprise System

Platform™ (BH-ESP) to meet and exceed the RFP system

expectations and requirements with respect to demographic

data submission. The platform is powered by the Aetna EDI

Gateway that serves mission critical information sharing for

the state of Arizona today, including demographic data

submissions.

MMIC will thoroughly review and comply with the

submission of demographic data to ADHS/DBHS as

specified in the CIS File Layout and Specifications Manual

and according to the submission timelines in the ADHS/DBHS Provider Manual, 7.5 Enrollment,

Disenrollment and Other Data Submission, the DBHS Demographic and Outcome Data Set User

Guide and the ADHS/DBHS Office of Program Support Operations and Procedures Manual.

17.19.2 Include a Written Attestation with Each Demographic Data Submission

In conformance with section 17.2.6 of this RFP, MMIC will provide attestation at the time of

submission that any data transmitted is accurate, complete and truthful, to the best of the

contractor‘s Chief Executive Officer (CEO), Chief Financial Officer (CFO) or designee‘s

knowledge in conformance with the AHCCCS HIPAA Transaction Companion Guides and

Trading Partner Agreements, and the AHCCCS Encounter Manual (42 CFR.438.606).

Figure 1: EDI Gateway currently processes

demographic transactions with the state and complies

with CIS file layout and specifications.



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Demographic data is the driving force behind monitoring and reporting on enrolled clients’

outcomes, ensuring compliance with federal and state funding and/or grant requirements,

assisting with financial-related activities such as budget development and rate setting, supporting

quality management and utilization management activities, and responding to requests for

information. In order to achieve the timelines regarding enrollment, change, annual or six-

month outcome measures updates and disenrollment, the RBHA needs to provide a top-notch

technology solution combined with process knowledge and capable staff. MMIC will leverage

the experience of MCP combined with best in industry technology to establish a consistent

workflow of data from provider to RBHA and RBHA to ADHS/DBHS.

17.20 Grievance, Appeals, and Claims Dispute Data Submissions When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:

Mercy Maricopa Integrated Care (MMIC) recognizes that members may face issues requiring a

means for them to express complaints and resolve disputes. One of our organization’s core

values is member satisfaction, and we will support it through the careful recording and reporting

of member issues.

MMIC – through its sponsors, Mercy Care Plan (MCP) and Maricopa Integrated Health System

(MIHS) – will have a complete, integrated system in place to record, track, resolve and report

grievances and appeals. Our grievance and appeals processes will provide a mechanism for our

members or their representatives to express complaints, resolve disputes, or bring attention to

incidents, conditions, practices and/or policies that may violate their rights.

We will maintain individual complaint records that include adequate, dated documentation,

including:

Copies of communication generated during the resolution process



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Documentation of actions taken to meet immediate health care needs

Documentation of all steps taken to resolve the issue, including the date the complaint was

acknowledged and the date the complainant was notified of resolution

Documentation of plans for resolution

Documentation of plans for correction

Evidence that the resolution and any plans for correction have been implemented

Evidence that identified issues are referred for additional follow up as indicated, including

referrals to Quality Management, Network Management, Grievance and Appeals, Fraud and

Abuse departments and/or regulatory agencies

The reason for delay for complaints taking more than 10 business days from filing to resolve

17.20.1 Submit Grievance and Appeal Information to ADHS/DBHS Database

17.20.2 Submit Initial and Updated Entries within Three Working Days

MMIC will submit grievance, appeal, request for hearing information and provider claim dispute

information into the ADHS/DBHS Office of Grievances and Appeals database, as required. In

addition, we will submit initial and updated entries to the ADHS/DBHS Office of Grievances

and Appeals database within three working days of an event requiring entry.

We will track and maintain a log of all grievances received, utilizing the following data fields for

submission to the ADHS/DBHS Office of Grievances and Appeals database:

The enrollee’s first and last name

The date the complaint was made

Title XIX/XXI eligibility status

The source of the complaint

A description of the grievance



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Any identified communication need, such as a translator

The outcome reached

The length of time for outcome

Covered service category

Treatment setting

Behavioral health category

Our Grievance Administrator will have responsibility for collecting, recording and maintaining

this data for submission to the ADHS/DBHS Office of Grievances and Appeals database.

Defining Complaints, Grievances and Appeals

MMIC will define a complaint as an expression of dissatisfaction with any aspect of care other

than the appeal of an action involving Title XIX/XXI recipients. Complaints will include

concerns about the quality of care or services, aspects of interpersonal relationships with service

providers, and lack of respect for recipients’ rights. Complaints will be promptly resolved by

informal means, such as immediate staff action or phone call.

MMIC will define a grievance as a complaint filed by a member with SMI or other concerned

person regarding violation of the rights of the member with SMI or a condition requiring an

investigation. It can be a formal written or verbal complaint (when the verbal complaint about

member care is unresolved at the time by staff present) by a member or representative, regarding

care, abuse or neglect, issues related to the hospital’s compliance with Centers for Medicare and

Medicaid Services (CMS) Conditions of Participation, or a Medicare beneficiary billing

complaint related to rights and limitations provided by 42 CFR§489. The following are

considered to be grievances:

A member care complaint that cannot be resolved at the time by staff present, is postponed

for later resolution, referred to other staff for later resolution, requires investigation and/or

further actions for resolution



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Situations where members or their legal representatives contact the hospital after discharge

about concerns related to care or services that were not resolved during their stay or that they

did not wish to address during their stay

Whenever a member or legal representative requests that the complaint be handled as a

formal complaint or grievance, and/or requests a response from the hospital

A written complaint, whether from an inpatient, outpatient, released/discharged member or a

representative, regarding care provided, abuse or neglect, or the hospital’s compliance with

CMS Conditions of Participation. E-mail or fax is considered “written.”

When an identified member writes or attaches a written complaint to a patient satisfaction

survey and requests resolution

MMIC defines an appeal as a request for review of a decision made by ADHS/DBHS, T/RBHA

or T/RBHA provider. There are three types of appeals as follows:

Appeal Section 5.2/GA 3.1: A request for review of an adverse decision by T/RBHA or

ADHS/DBHS for a person determined to have a serious mental illness

Appeal Section 5.1/GA 3.3: A request for review of an action

Appeal Section 5.5/Appeal GA 3.5: A request for review of a decision made by

ADHS/DBHS, a T/RBHA or a T/RBHA provider

Handling Grievances Appropriately and Expeditiously

MMIC is committed to handling grievances in an appropriate and expeditious manner. To this

end, we will develop the following procedures for specific resolution time frames, key

individuals responsible for acting to resolve the grievance, and processes for reporting the

grievance, appeal, request for hearing information and provider claim dispute information into

the ADHS/DBHS Office of Grievances and Appeals database as required.



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Our Grievance Administrator will be responsible for:

Tracking to make sure that all grievances are reviewed, investigated and resolved as soon as

possible, depending on the severity of the issue. Once a Member Advocate receives a

grievance, it will be documented according to the appropriate facility reporting process.

Grievances about situations that endanger the member, such as abuse or neglect, will be

investigated immediately

Involving applicable departments, such as Risk Management, Quality Improvement, and

Compliance, and staff, such as Department Manager and/or Director, Chief Medical Officer,

Chief Operating Officer and/or Chief Executive Officer, as necessary, to appropriately

investigate and resolve the grievance

Responding in writing to each member grievance within five days of submission

Upon resolution, the Grievance Administrator will include in the written response

Name of the hospital contact person

Steps taken on behalf of the member to investigate the grievance

Results of the grievance process

Date of completion

If the grievance is unresolved, the investigation is incomplete, or corrective action is still being

evaluated, required written response, within seven days of submission, the notice will explain

that MMIC is still working to resolve the complaint and those we will follow up with further

written responses, within specified time frames, until the process is completed.

We will provide written notice of determination regarding the grievance to the member or

member representative in a language and manner that is easily understood. MMIC will keep the

completed grievance file in the Risk Management department for record keeping and data

management purposes. If the grievance involves allegations of malpractice, negligence or is an



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actual claim against MMIC, it will be immediately directed to Risk Management for review and

follow up.

When MMIC receives notice, either orally or in writing, that an individual has Limited English

Proficiency (LEP) or any other communication need, we will follow internal policies regarding

oral interpretation services, translation of written materials, and services for the deaf and

hearing-impaired:

We will make oral interpretation service available for all individuals with LEP.

We will provide written translation for individuals needing assistance in the prevalent non-

English language within the region.

We will provide oral interpretation of written materials, or make alternative communication

formats, (such as TTY/TTD), available for those needing assistance in a language not

considered a prevalent non-English language, as needed.

Our Appeals Manager will ascertain that individuals making decisions regarding appeals have

not been involved in any previous level of review. The Appeals Manager will also make sure

that individuals making decisions about appeals involving denial of an expedited resolution, or

involving clinical issues are health care professionals with the appropriate clinical expertise with

the member’s condition.

Strategies for An Implementation Plan Consistent with 18.24.5

MMIC’s Grievance Administrator, in collaboration with our Implementation team, will initiate

strategies concerning Complaint, Grievance and Appeal processes. They include:

Developing written Policies and Procedures in accordance with State and Federal regulations,

including:

How we will define Complaints, Grievances and Appeals and respond to each



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How we will track and log Complaints, Grievances and Appeals in our QNXT system,

including all required state and federal databases

How we will enter and submit appeals data to ADHS/DBHS Office of Grievances and

Appeals

Use of peers as member advocates

The role of the Human Rights Administrator

Pertinent language concerning our processes in our Member Services Handbook

Posting both the Member Handbook and Provider Manual on our website, and providing hot

links to the ADHS/DBHS Provider Manual

Establishing requirements for QNXT’s internal tracking of Complaints, Grievances and

Appeals, performing gap analyses, and creating enhancements to the system as needed

Conducting follow-up testing prior to “go-live” as part of readiness review

Collaborating with ADHS/DBHS on development, and participating in meetings at their

discretion

Developing training curricula on relevant processes for internal and provider staffs

Providing training to internal and provider personnel on relevant processes

Mercy Maricopa Integrated Care (MMIC) will handle all grievances and appeals in an

appropriate and expeditious manner. Our processes will provide uniform, equitable treatment

and prompt response of grievances and appeals. We believe that member satisfaction is achieved

through the expeditious resolution of grievances and appeals, and will endeavor to provide a high

level of issue resolution across all organization departments in pursuit of excellence.



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18.4 Peer Involvement and Participation Offeror Response:

Mercy Maricopa Integrated Care (MMIC) is committed to a system of care that engages the

individuals receiving services at every level: through driving their own treatment planning

process, providing peer delivered services, engaging in community development work, and

making system improvements in administration and service delivery. MMIC’s Office of

Individual and Family Affairs will take on a leadership role in creating opportunities for and

confirming peer involvement at all levels of the system. In addition to quality oversight to

confirm peer involvement in treatment planning, MMIC, through its sponsor organizations, has

established the following mechanisms for peer involvement:

1. Office of Individual and Family Affairs-sponsored activities and forums including but not

limited to: round table discussions, information sessions, participatory dialogues, and system

of care planning meetings.

2. Peer representation on MMIC committees and governing bodies including the Governance

Committee, Board of Directors, Strategy Committee and all its sub-committees, Integrated

Clinical Care and Quality Management Committee and all its sub-committees, Audit and

Compliance Committee, Member Advocacy Committee, Youth Leadership Council, Finance

Committee, and CLAS Committee.

3. Participation in quality management activities, including but not limited to: conducting

surveys and review mechanisms such as the Recovery Oriented Systems Indicators (ROSI)

and the Recovery Assessment Scale (RAS), as outlined in more detail in the Quality

Management Section of this proposal.

4. Participation in joint review efforts when assessing adherence to the Intergovernmental

Agreement and Collaborative Protocol between AZ Department of Economic

Security/Rehabilitation Services Administration and MMIC’s government partner, Maricopa

Integrated Health System (MIHS).



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5. Participation and leadership on the SMI Clinic Advisory Councils for each SMI Clinic.

6. Participation in the interview process when hiring for all direct service staff positions.

7. Increased use of peer support services, number of certified Peer Support Specialists, and

Consumer Operated Service Programs.

8. Use of peer and family advocacy groups to serve as Member Advocates for members

participating in the grievance and appeals process.

9. Provision of educational/training opportunities to assist peers in gaining the skills needed to

be effective self-advocates and system-advocates, including an emphasis on taking charge of

one’s own treatment and the treatment planning process.

10. Peers and peer/family advocacy groups involvement in delivery of training to provider staff

and other workforce development efforts – such as NAMI’s Signature Provider Training and

In Our Own Voice presentation.

11. Peer leadership in the planning and implementation of Annual Conference for Change.

12. Participation in ADHS/DBHS initiatives to improve communication and input such as

participatory dialogues (Arizona Dialogues), recovery roundtables, and a collaborative

approach to completing Recovery Roadmaps.

13. Sharing recovery stories in committee meetings, reports, and Newsletters to highlight

strengths and success while creating a culture of celebration.

18.4.1 Participation of At Least One Peer or Family Member During the Interview Process

MMIC believes peers should be an integral part of the interview process and treated like anyone

else conducting interviews. Peers bring an important perspective to the interview process when

hiring staff. They bring lived experience and experiential knowledge into play in addition to

traditional knowledge about providing support. They can assess candidates from a very personal

perspective, providing valuable information to the rest of the team. As such, they will have a

voice in the hiring decision equivalent to any other interviewer.



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MMIC will require that providers demonstrate documentary evidence that they have involved

peers (including youth when applicable) in the interview process when hiring all direct service

staff. Provider adherence to this requirement will be monitored quarterly by the MMIC Quality

Management Department. Peers will not only be involved in interviewing direct service staff but

key administrative staff as well. Administrative staff will include positions that are in the

supervisory chain of command for direct service staff, such as Supervisors, Site Managers,

Clinical Directors, and Chief Executive Officers. We believe that including peers in interviews

for these positions sends both candidates and peers an important message about the centrality of

recovery to all that we do, while also creating a mechanism to select candidates who believe in

recovery.

Through MMIC’s Office of Individual and Family Affairs and a partnership with local National

Alliance on Mental Illness (NAMI) affiliates, peers will be identified and recruited to participate

in provider interviews. The Technical Assistance Center (TAC), created in partnership with

Arizona State University (ASU), Maricopa Integrated Health System (MIHS), and community

stakeholders (as outlined in more detail in section 4.4-4.6), will also play a major role in

recruiting peers to participate in interviews. The TAC will offer self-advocacy and system-

advocacy training for peers. Many participants in these training programs may be matched with

paid opportunities to get involved in the system, especially through participating in interviews.

The TAC staff will use their expertise in industrial/organizational psychology to provide

assistance to peers and providers in developing meaningful training programs for peers.



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18.4.2 Develop a Process for Members to have Regular and Ongoing Input

SMI Clinic Advisory Councils

MMIC will enable members to have regular and ongoing input to assist in decision-making,

development, and enhancement of customer service at each provider site where case

management services are delivered through participation and leadership on the SMI Clinic

Advisory Councils for each SMI clinic, in addition to the aforementioned quality management

efforts and committee involvement as outlined above.

Each SMI clinic will be required to continue its SMI Clinic Advisory Council, which allows

members, families, and other stakeholders to address concerns and make recommendations for

improvement via monthly meetings. The SMI Clinic Advisory Councils will be authorized to

make recommendations and decisions. They will have regular opportunities to meet with clinic

leadership and MMIC administrators. The goal of the SMI Clinic Advisory Council is to bring

staff, individuals receiving services, family members, neighboring businesses, and other

community members together to collaborate and take ownership of their clinic, their

neighborhood, and their community. MMIC embraces the fact that the best ideas and solutions

come from the individuals who are directly affected by the system; especially those receiving

services and those providing services at the front line. This strategy builds community through:

Creating shared ownership;

Increasing neighbors/community members awareness of the value of the clinic and the

realities of mental illness and recovery;

Helping staff feel empowered and develop stronger connections to their jobs;

Helping individuals receiving services feel empowered and develop ownership of their

recovery journey while increasing leadership and employment skills;

Decreasing the power differential as staff and individuals receiving services work side-by-

side to make meaningful changes.



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To assist all councils in improving their impact, we will contract with Recovery Empowerment

Network to offer a condensed version of its Arizona Transformation Statewide Consumer

Network (ATSCN) training to members of all advisory councils. This training is designed to

provide individuals with the skills needed to be effectively involved in transforming the

integrated system of care through participation and involvement in advocacy efforts and decision

making/advisory bodies.

ATSCN training will be provided in a one-day session at each SMI clinic that decides to take

advantage of it. Through this training, advisory council members gain a thorough understanding

of recovery, its principles, and what a recovery-oriented system might look like. The training

covers attitudes and self-esteem, group process, advisory council functions and policy

development. In addition to preparing various stakeholders to become effective advocates on the

advisory council and to develop a stronger understanding of recovery, such training efforts have

been proven to make a significant impact on individuals with mental illness – leading to

significant improvements in symptom control, social relationships, personal care and vocational

skills.

MMIC will require that SMI clinic leadership commit to each SMI Clinic Advisory Council

taking on meaningful roles and decision making authority. Some of the roles will include:

Completing the ADHS/DBHS Recovery Roadmap, making recommendations for continued

improvement, implementing recommendations, and monitoring progress;

Establishing mechanisms to assess customer satisfaction;

Reviewing customer satisfaction data, including clinic-based complaints and suggestions,

and make and monitor recommendations for continued improvement.

Other roles will be determined by each individual Advisory Council. As an example, such

activities may include:

Neighborhood beautification projects and other community-based volunteer projects;



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Strategies for outreaching and engaging the community;

Suggesting trainings/workshops and other activities to offer individuals receiving services;

Identifying system gaps and working with the community to organically fill these gaps.

SMI clinic leadership/administrators will be expected to be available and meet with the Advisory

Council upon the Council’s request. MMIC administrators will also be available to meet with or

attend Council meetings upon request. The MMIC Office of Individual and Family Affairs will

meet with each Council quarterly to confirm their presence, to monitor that the provider agency

is meeting its requirements to utilize the Council’s feedback and to afford them meaningful roles

and decision making authority; and to offer any support needed. Furthermore, the Office of

Individual and Family Affairs will gain new insights through meeting with each Council and will

utilize these insights in system of care planning efforts.

In addition to the SMI clinic advisory councils at the provider level, MMIC is committed to

having meaningful peer involvement in all its advisory and decision-making bodies. Below is a

more detailed description of two of these bodies.

Governance Board

The composition of MMIC’s Governance Board and its functions are described in Section 18.22.

To encourage active participation from members, MMIC will make special efforts to increase the

involvement of members who are on the Board in discussions during the meeting and help

strengthen their ability to impact decisions.

We will contract with Recovery Empowerment Network to provide a condensed version of its

Arizona Transformation Statewide Consumer Network (ATSCN) training to all Governance

Board members. This training is designed to provide individuals with the skills they need to be

effectively involved in transforming the integrated system of care through involvement on

groups such as the Governance Board.



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ATSCN training will be provided in a one-day session. It will help all Governance Board

members gain a thorough understanding of recovery, its principles, and what a recovery-oriented

system might look like. It will cover attitudes and self-esteem, group process, and Board

functions and policy development.

In order to create an environment that promotes advocacy and professional growth, Governance

Board members may have access to a professional mentor and/or may be asked to become a

mentor to newer advocates.

Member Advisory Council

MMIC will form a Member Advisory Council to advise on issues that are important to members.

Composed of twelve members that meet monthly, the Council will promote choice and the

development of peer-operated services. Attendance at meetings will be a requirement of

membership and transportation will be provided to those without a source of transportation.

MMIC is committed to creating paid professional positions for individuals with lived experience.

Members of the Advisory Council will receive a stipend for their services.

Members will serve on the Council for two years and will go through the same trainings as

members who serve on our Governance Board. They will also receive ongoing training in areas

such as quality assurance and member rights during their terms.

The Council will provide system oversight and will address and recommend solutions on issues

related to access, complaints and grievances, customer service, satisfaction, quality

improvement, member concerns, provider availability, among others. The Council will review

and make recommendations on information developed for members, such as Newsletters and

website content.

The Council will also make recommendations about practice guidelines, utilization data, and

outcome tools. It will identify gaps in services and make suggestions regarding additional

services, suggest ways to improve the effectiveness of services, and make recommendations as to



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how best to meet the needs of members. Council members will also be asked to participate in

provider monitoring and quality management review efforts as appropriate.

Underscoring the value of the Council’s input, MMIC’s leadership, including clinical leadership,

will be present for each meeting to provide information and listen to recommendations from the

participants.

Meetings of the Council will be open to all members and widely publicized with attendance

encouraged. Discussions will be open to all members in attendance whether or not they are a

member of the Council. Members who are not a part of the Council may also be a part of task

groups formed by the Council.

Feeding into the Council will be a Youth Leadership Council composed of eight youth. Two

members of this Council will serve on the Member Advisory Council. A MMIC staff member,

selected by the youth, will serve as a mentor to the Council. The Youth Leadership Council will

provide an opportunity for youth to have a meaningful voice in our operations. It will address

issues of concern to youth, develop recommendations, and bring those recommendations into the

Member Advisory Council. Involvement in this group will not only enrich MMIC, but also

prepare youth for leadership roles in their communities.

MMIC’s Office of Individual and Family Affairs will interact closely with both advisory

councils and will play an active role in member recruitment and support.

18.4.3 Develop a Written Description of the Process for Members to Have Regular and

Ongoing Input and

18.4.4 Required Inclusions to Written Description

We have outlined twelve mechanisms for peer involvement and participation at every level of the

system. Upon contract award and prior to contract implementation, MMIC will develop a



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written description which details the process for each of these twelve strategies. This description

will include requirements that the members attend regular meetings with clinical leadership and

that they be authorized to make decisions. MMIC will collaborate with established peer and

family advisory bodies, such as the Arizona Peer and Family Coalition, to seek input in the

development of these important processes. MMIC will submit the description to ADHS/DBHS

for review, input, and approval. After implementation, MMIC will revise descriptions as needed

based on the feedback of the peers and family members who are involved in implementing these

twelve strategies.

18.8 Training of Contractor Personnel, Subcontractors and Providers When responding, include Offeror’s strategies for training and cross-training the behavioral and physical

health care workforce to operate in an integrated health care system. Offeror Response:

Leveraging the resources and experience of its non-profit sponsors Mercy Care Plan (MCP) and

Maricopa Integrated Health System (MIHS), Mercy Maricopa Integrated Care (MMIC) will

provide training and educational opportunities at no cost to providers, members and the

community as a whole. Through a centralized Learning and Performance Center, we will offer

tailored training curricula and content to meet training requirements in the ADHS/DBHS

Provider Manual 9.1 as well as build awareness, skills and knowledge to support an integrated

delivery system. Our training program will help link people, learning and performance to:

Promote a consistent philosophy and equip employees and providers with the appropriate

knowledge of the delivery system

Facilitate education and cross-training of the behavioral and physical health workforce to

maximize the effectiveness of an integrated health care system

Support the delivery of services in a manner consistent with Arizona system principles

Provide timely information on new initiatives, technological advances, and best practices that

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MMIC will monitor the effectiveness of its training programs and refine training content and

delivery as necessary to increase effectiveness. Training will be delivered using a variety of

methods, including:

Traditional classroom-led training

Interactive learning (group activities, role playing, discussion)

Online training through Essential Learning for more convenient access to courses

Self-study materials that can be reviewed independently

Technical assistance, coaching and mentoring provided by training professionals, peers and

family members

18.8.1 Sufficient Number of Qualified Trainers who are Subject Matter Experts in

Training Topic

As part of implementation, MMIC will hire dedicated and qualified training staff. Training

personnel will develop curricula and deliver initial and ongoing trainings to enhance the

knowledge and skills of all MMIC personnel, network providers, members, family members who

provide peer support and system stakeholders.

MMIC will employ a Training and Workforce Development Administrator who will oversee the

development, implementation and oversight of training programs as well as workforce

recruitment. Additionally, MMIC will build upon its sponsor organization Mercy Care Plan’s

(MCP) existing Learning and Performance Center (LPC). The LPC offers dedicated trainers to

support employees. All trainers hold bachelor’s degrees or equivalent training; trainers who

provide clinical training all hold degrees. All have relevant health care knowledge and are

seasoned professionals in the training field.

MMIC will use existing provider training staff at MCP where possible, given that some training

required by existing contracts will also be required by this contract (cultural competency, fraud



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and abuse). MMIC will also augment the existing personnel with additional staff possessing

specific clinical, administrative, operational or personal (e.g., a peer or family member)

knowledge of behavioral health and of the Maricopa County system.

Additionally, MMIC will implement an electronic learning (e-learning) component, such as

Essential Learning, to provide increased training capacity in the most cost-effective manner. E-

learning will provide online learning resources to all stakeholders, including members and their

families, members of the community, providers, internal staff members and system partners in a

convenient and easily accessible manner.

18.8.2 Allocate Financial Resources to Provide Initial and Ongoing Training

MMIC will allocate financial resources both to provide and to maintain a comprehensive initial

and ongoing training program. A training budget will be set aside for staff salaries and e-

learning implementation and maintenance. MMIC will have 17 Full Time Equivalents (FTEs)

fully dedicated to the training of RBHA staff and providers. These staff will be supplemented

during implementation and as needed thereafter by our administrative services subcontractor,

Schaller Anderson’s Learning and Performance Center. MMIC’s Training and Workforce

Development Administrator will be fully responsible for our training program and collaboration

with the Learning and Performance Center administrator. The Training and Workforce

Development Officer will report to the Vice President of Operations. Annually, we will

appropriate the necessary funding for internal staff and provider staff training programs

including dedicated monies for e-learning initiatives and programs for Continuing Medical

Education (CME) and Continuing Education Units (CEUs).



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18.8.3 Provide Training, Coaching, Modeling, Technical Assistance and Observation

Training is a term often used in a nebulous manner to describe the various activities an entity

will offer with the intent of educating involved parties. MMIC defines training differently:

training includes the delivery of specific actions designed to disseminate knowledge and enhance

skills and performance.

MMIC’s comprehensive training program will be intensive, focused and aligned with company

guidelines, federal and state requirements and the requirements of the following agencies,

entities or legal documents as referenced in Exhibit 7:

Arizona Department of Health Services/Division of Behavioral Health Services

The Arizona Health Care Cost Containment System (AHCCCS)

The Arnold v. Sarn and JK v. Humble settlement agreements

The Maricopa County Superior Court

We will disseminate information to external parties in the form of curricula and technical

assistance primarily via live presentations, e-training modules and collaborative meetings.

MMIC employees will participate in the aforementioned activities and will also receive

supervision in accordance with regulatory requirements and MMIC policy. We will provide

supervision with the intent to maximize individual and departmental functioning and may

include techniques such as observation, coaching and modeling to help employees develop and

or enhance the skills necessary to make them an effective part of the team.

MMIC will identify and continually monitor the need for knowledge transfer, skill building and

performance improvement of personnel, providers, members and family members and other

stakeholders in order to tailor the training we provide. The following describes the customized

activities we intend to provide in order to both educate and support all involved parties.



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Training MMIC Personnel

Through the centralized LPC, we will provide training

specifically related to an employee’s job responsibilities and

goals via classroom sessions, web-based learning, shadowing

and mentoring. MMIC will provide a comprehensive

orientation and training program designed to educate new staff

on the mission, values and commitment to high-quality,

integrated care for members served as the RBHA for Maricopa

County. Essential program components will include:

Creating a comprehensive overview of our culture, including values and ethics, and how

these elements support our commitment to focus on members and providers

Building cultural competency and health literacy knowledge and skills to address member-

specific cultural and language needs

Dispelling the myths, stigmas, or other misperceptions associated with mental illness through

current and factual information

Verifying that staff participated and successfully completed required training

Completing position-specific on-the-job training, shadowing experienced staff in a hands-on

setting, accessing position-specific policies, procedures and other helpful resources.

Providing extensive and detailed information on technology and system tools that will

support personnel in performing their duties and enhance their ability to work efficiently

To measure the effectiveness of training, MMIC will use Kirkpatrick’s Four-Level Evaluation

Model, a nationally accepted, well-known model for objectively analyzing the effectiveness and

impact of training. The first level includes surveys completed after completion of training; the

second level includes assessments that are infused in the training to measure comprehension; and

the third level measures impact. MMIC’s sponsor, Mercy Care Plan (MCP), currently uses the

On a scale of 1 through 5, the current score based on survey feedback for the year is

4.77 indicating employee satisfaction with the delivery and content of training.



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first and second levels, and is developing plans to implement the third level, which measures an

employee’s job performance 45-90 days after training.

Ongoing Training

MMIC will require mandatory ongoing training for key areas including but not limited to

compliance, quality of care concerns/services, cultural competency, reporting member/provider

complaints, code of conduct, and fraud and abuse. Managers and Supervisors will be

accountable for ongoing employee training specific to job functions. Ongoing training will be

delivered primarily through the Learning and Performance Center’s online classes, but may also

occur through instructor-led training sessions, in-services, presentations and handouts. Training

will be reinforced and updated through periodic departmental meetings and in annual training

classes.

Training Providers

We are committed to offering a well-developed provider training program that promotes

consistency, culturally competency, best practices, and that equips all behavioral and physical

health providers with the information necessary to operate in an integrated delivery system and

to provide the highest quality of services to members. This comprehensive provider training

program will comply with ADHS/DBHS requirements as outlined in Exhibit 7 and the

ADHS/DBHS Provider Manual, Section 9.1. We will solicit input from providers on training

topics needed as well as the development and delivery of training content. MMIC will also offer

technical assistance to providers when issues or deficiencies are identified.

In addition, we will require providers to train their staff in meeting the needs of members served.

These requirements vary by provider type and qualifications of staff. Ongoing staff training at

provider offices will be designed to improve overall staff competencies and, at a minimum, occur

when policies and procedures change, the Provider Manual changes, when new ADHS/DBHS or

RBHA initiatives are instituted, and in accordance with contract requirements. Training methods



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will include computer-based, live, coaching/mentoring, technical assistance and self-study.

MMIC will monitor providers to assess competency on required topics.

Through Essential Learning, MMIC will give providers access to a variety of training

opportunities. E-learning capabilities allow our providers and stakeholders to receive

information and training at times that are most convenient while also helping them track and

monitor their progress. The function also allows for customization of courses to meet specific

requirements. Many courses also provide nationally accredited continuing education units.

Training Peers and Family Members

MMIC will incorporate a variety of approaches to educate, inform and train peers and family

members. We understand the importance of involving and collaborating with peers, family

members, peer- and family-run organizations and stakeholders as part of transforming the system

to one driven by integrated care and recovery. To that end, we will offer training, technical

assistance, and skill-building programs for members and their families in areas such as

leadership and advocacy, program development, resource identification and coordination.

Training will be a component of MMIC’s Office of Individual and Family Affairs, staffed by

peers and family members. The Office of Individual and Family Affairs is designed to increase

adult, youth and family voice at all levels and place peers and family members at every level of

the system. We will support the development of peer and family support services and will

partner with local organizations to offer peer support training.

18.8.4 Input from Members and Family Members in Training Curricula and Delivery

We believe obtaining members’ and family members’ perspectives and feedback is pivotal; thus,

we will involve members and families at all levels of the system, including development and

delivery of training. Members and family members will be key participants in our annual



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conference for change as well as through participation in community meetings, on our

Governance Board and Member Advisory Council, and other advisory committees.

MMIC will engage members to not only participate but also have an impact. We will use family

members, peer-run, family-run and parent-support organizations to provide technical assistance,

training, coaching and support to peers, family members and youth who assume leadership roles

within the delivery system.

Recognizing the importance of family-run organization, MMIC will be committed to building

and maintaining partnerships with these organizations. MMIC’s sponsors, Mercy Care Plan and

MIHS, have extensive experience working with local, peer and family-run organizations. MCP

works cooperatively with these organizations in current AHCCCS programs managed by the

plan and MIHS makes use of these resources in conjunction with its community health centers,

outreach programs and hospital services.

We believe these organizations can play an integral leadership role in sustaining family

involvement and support as well as in system transformation. Via leadership and technical

assistance activities, these family-run organizations can help connect an “authentic” family voice

to the delivery system. As part of this, we will engage family-run organizations to provide

coaching, mentoring and training to family members employed in the system and family leaders

in the community. Further, we will work with family-run organizations to assist in designing

curriculum for families on the Arizona Vision, Principles, Child and Family Team (CFT)

practice, and family-driven and youth-guided care.



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18.8.5 Provide Initial and Ongoing Training for Staff, Providers, and Stakeholders to

Become Knowledgeable and Skilled in an Integrated Health Care Service Delivery System

MMIC will provide initial and ongoing training on the integrated health system and related

topics for staff, providers and stakeholders. Our goal is to educate members and providers so

they can be full participants in the integrated delivery system and achieve the greatest benefits

from the system as a result. We will also infuse information on the integrated delivery system

throughout our educational materials and reinforce this through ongoing training.

MMIC’s sponsors, MCP and MIHS, bring extensive experience in educating and training

providers to promote the integration of care. MMIC will build upon this experience and success

to offer similar and enhanced training programs so that staff, providers and stakeholders will be

educated and knowledgeable on an integrated health care delivery system. For example, MCP

currently offers the Integrated Care Training Academy, a training initiative that focuses on

supporting healthcare professionals in delivering integrated care services. Via a series of

campus-based training services, MCP educates primary care physicians, skilled nursing

facilities/assisted living facilities and behavioral health professionals on addressing the whole

person, including physical and behavioral needs.

Technical Assistance Center

Through a partnership with MIHS and Arizona State University (ASU), MMIC will develop a

community-embedded Technical Assistance Center (TAC). The TAC will, among other

initiatives, provide continuing educating, technical assistance and programmatic consultation.

This includes using ASU’s more than 10-year history as a SAMHSA-funded Addiction

Technology Transfer Center to operate a system-wide continuing education center, comprised of

online and in-person learning opportunities for physical and behavioral health practitioners on

evidence-based health topics. In addition, the center will provide organizational coaching and



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consultation to provider agencies to assist in integrated physical and behavioral health program

conceptualization, implementation and evaluation.

In addition, MMIC will leverage relationships with ASU, the Aetna Foundation, MIHS and

SCHN Graduate Medical Education Programs to develop integrated health programs that offer

continuing education units. We will also establish local relationships with the National Alliance

for the Mentally Ill (NAMI). Education on an integrated health care service delivery system

must include evidence-based behavioral health practices and chronic condition management for

conditions prevalent in the SMI population and engagement strategies for persons receiving

services and their families. Multiple training delivery methods will be used to include webinars,

presentations, and toolkits.

18.8.6 Include a Cultural Competency Component in Each Training Topic

MMIC values and understands the importance of delivering culturally responsive services. To

that end, we will incorporate a cultural competency component in each training topic delivered to

staff, providers and stakeholders. MMIC will address the cultural relevance and considerations

pertinent to each training topic in accordance with the ADHS/DBHS Provider Manual Section

9.1 Training Requirements and our Cultural Competency Plan. All of our trainings will be

reviewed for cultural appropriateness, relevance and delivery.

18.8.7 Collaboration with ADHS/DBHS to Coordinate and Deliver Training

We understand the transforming the system requires a strong partnership between MMIC

ADHS/DBHS, AHCCCS and all system stakeholders. MMIC will collaborate with

ADHS/DBHS to coordinate and deliver training initiated by ADHS/DBHS in response to

identified needs.



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18.8.8 Orientation and Training for Providers New to the Field of Health and Network

MMIC will provide orientation and training for all providers new to the network. In addition,

through our sponsor organization, MIHS, MMIC will provide orientation and training for

providers new to the field of health. In accordance with the ADHS/DBHS Provider Manual,

Section 9.1, we will require behavioral health providers to complete the following training

content before providing services and within 90 days of the staff person’s hire date, as relevant to

each staff person’s job duties and responsibilities: Table 1 below and continuing on the following

pages describes the training that is required.

Table 1: Behavioral Health Provider Training (within 90 Days of Start Date)

Specific Training

Screening for eligibility, enrollment for covered behavioral health services (when eligible), and referral

Use of assessment and other screening tools (e.g., substance-related, crisis/risk developmental, etc.), including the Birth-to-Five Assessment depending upon population(s) served

Application of diagnostic classification systems and methods depending upon population(s) served

Use of effective interview and observational techniques that support engagement and are strengths-based, recovery-oriented, and culturally sensitive

Behavioral health service planning that addresses the client’s/family’s needs as identified through initial and ongoing assessment practices


Use of effective interview and observational techniques that support engagement and are strengths-based, recovery-oriented, and culturally sensitive


Confidentiality/HIPAA



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Specific Training

Coordination of care requirements with Primary Care Providers (PCPs)

Sharing of treatment/medical information

Management of difficult cases, including high-risk persons and persons court ordered for treatment

Covered behavioral health services (including information on how to assist persons in accessing all medically necessary covered behavioral health services regardless of a person’s behavioral health category assignment or involvement with any one type of service provider)

Overview of Substance Abuse Prevention and Treatment Block Grant: Priority placement criteria, interim service provision, consumer wait list reporting, and expenditure restrictions of the Substance Abuse Prevention and Treatment Block Grant

Early, Periodic, Screening, Diagnosis and Treatment (EPSDT) Program

Rights and responsibilities of eligible and enrolled behavioral health recipients, including rights for persons determined to have Serious Mental Illness

Appeals, grievances and requests for investigations

Complaint Process

Customer/member service

Fraud and abuse requirements and protocols

Managed care concepts, including information on the T/RBHA and the public behavioral health system

Overview of Arizona behavioral health system policies and procedures, including the ADHS/DBHS system principles

Arizona Vision and 12 Principles in the children’s system 9 Guiding Principles for Recovery Oriented Adult Behavioral Health Services and Systems in

the adult system

Best practices in the treatment and prevention of behavioral health disorders

Clinical training as it relates to specialty populations and/or conditions

Information regarding the appropriate clinical approaches when delivering services to children in the care and custody of ADES/DCYF



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Specific Training

Overview of partnership with Department of Economic Services/Rehabilitative Services Administration

Cultural competency

Child and Family Team (CFT) practice, depending on the population(s) served

Third party liability and coordination of benefits

Claims/encounters submission process

Advance Directives

Identification and reporting of persons in need of Special Assistance for individuals who have been determined to have a Serious Mental Illness (SMI) and ensuring involvement of persons providing Special Assistance

ADHS/DBHS Demographic Data Set, including required timeframes for data submission and valid values

Medicare Prescription Drug Modernization and Improvement Act of 2003 (MMA), including the following (as required by the Balanced Budget Amendment):

Assisting persons in choosing a Medicare Part D plan; Accessing relevant resources (e.g., plan formularies); and Answering questions and obtaining informational materials

In accordance with the Office of Behavioral Health Licensure (OBHL) training requirements,

MMIC will train behavioral health technicians and behavioral health paraprofessionals so that

they have the skills, knowledge and core competencies necessary to perform duties consistent

with the position and services the agency is authorized to provide. Table 2 below and on the

following page describes the core competencies providers will achieve following our trainings.



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Table 2: Behavioral Health Provider Training – Core Competencies Core Competencies

Meet the unique needs of the client populations served by the agency or the staff member, such as children, adults age 65 or older, individuals who have substance abuse problems, individuals who are seriously mentally ill, or individuals who have co-occurring disorders

Recognize, prevent, and respond to a situation in which a client:

May be a danger to self or a danger to others

Behaves in an aggressive or destructive manner

May be experiencing a crisis situation, or

May be experiencing a medical emergency

Meet the unique needs of the client populations served by the agency or the staff member, such as children, adults age 65 or older, individuals who have substance abuse problems, individuals who are seriously mentally ill, or individuals who have co-occurring disorders

Recognize obvious symptoms of a mental disorder, personality disorder, or substance abuse

Protect and maintain the confidentiality of client records and information

Provide treatment that promotes client dignity, independence, individuality, strengths, privacy and choice

Provide the behavioral health services that the agency is authorized to provide and that the staff member is qualified to provide

Assist a client in accessing community services and resources

Record and document client information

Demonstrate ethical behavior, such as by respecting staff member and client boundaries and recognizing the inappropriateness of receiving gratuities from a client

Identify types of medications commonly prescribed for mental disorders, personality disorders, and substance abuse and the common side effects and adverse reactions of the medications

Recognize and respond to a fire, disaster, hazard, and medical emergency

Provide the activities or behavioral health services identified in the staff member's job description or the agency's policy and procedure

Training will be completed and documented in accordance with OBHL requirements (see R9-20-204(F) and R9-20-206)

Specialized Training

MMIC will provide abbreviated but specialized training as required by the Arizona Department

of Economic Security (ADES) and the Arizona Department of Health to Professional Foster



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Homes Providing Home Care Training to Home Care Client (HCTC) Services and Adult

Therapeutic Foster Homes.

Homes Serving Children

MMIC will monitor professional foster homes licensed by ADES for compliance with training

requirements in R6-5-5850. Training will include:

CPR and first aid training

30 hours of pre-service training utilizing Partnering for Safety and Permanence: the Model

Approach to Partnerships in Parenting (PS-MAPP)

18 hours of pre-service training utilizing the Arizona Home Care Training to Client Service

Curriculum

Behavioral health management of crisis situations including:

Prevention of violent behaviors,

Behavior management skills, and

De-escalation techniques

Medical/health care issues, procedures, and techniques, including the purpose/use/

administration of medications, interactions, and potential medication reactions

Homes Serving Adults

MMIC will require providers delivering HCTC services to adults to complete and credibly

document annual training as required by R9-20-1502. HCTC training will include:

Reading and implementing a person’s treatment plan; and

Recognizing and responding to a fire, disaster, hazard or medical emergency

Community Service Agencies (CSAs)

Community service agencies (CSAs) will submit documentation to MMIC as part of the initial

and annual CSA application indicating that all direct service staff and volunteers have completed



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training specific to CSAs prior to providing services to behavioral health recipients. Additional

training will be required for behavioral health providers in specific roles such as:

Assessors conducting the behavioral health assessment and children age birth to five

assessment

Providers responsible for service plan development and implementation

Child and family team facilitators

Child and family team coaches and Supervisors of CFT facilitators

Providers delivering services through distinct programs (e.g., Assertive Community

Treatment teams);

Providers offering specialized therapeutic approaches (e.g., Dialectical Behavioral Therapy,

Multi-Systemic Therapy);

Providers offering expertise in specialized areas (e.g., developmental disabilities, trauma,

substance abuse, children age birth to five);

Providers involved in Level I facilities;

Behavioral health providers providing services to children and families involved with Child

Protective Services (CPS) will be required to attend “Unique Needs of Children Involved with

CPS” training offered on a regular basis. In addition, specific situations may necessitate the need

for additional training. For example, quality improvement initiatives may require focused

training efforts. New regulations that impact the public behavioral health system may also

require concerted training strategies (e.g., Balanced Budget Act (BBA), Medicaid Modernization

Act (MMA) and Deficit Reduction Act (DRA)).

Training Expectations for ADHS/DBHS Clinical and Recovery Practice

MMIC will require behavioral health providers to complete training on published, selected

ADHS/DBHS Practice Protocols with required elements before providing services. We will also



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require providers to access and complete training expectations set forth by ADHS/DBHS on

required elements that are revised.

Continuing Training Requirements

In addition to training required within the first 90 days of hire, we will require our providers to

undergo ongoing training for the following content areas:

Ongoing provider training on procedures for encounter submissions. We will also provide

training to any provider with a data validation review rate greater than ten percent.

ADHS/DBHS Demographic Data Set, including required timeframes for data submission and

valid values

Ongoing education and training in culturally and linguistically appropriate service

Training Providers New to the Field of Health

As one of MMIC’s non-profit sponsors, training and education is a major component of the

mission of MIHS and by extension, MMIC. A major source of medical and allied health

education in the state, MIHS serves as a hub for all teaching institutions in Maricopa County as

well as all of Arizona providing teaching and educational experience for undergraduate as well

as graduate education programs.

Undergraduate Training Programs

From July 1, 2011 through June 30, 2012, 448 individual students completed 742 rotations

through MIHS clinical departments. Also, during the 2011-12 training year, 1636 individual

nursing and allied health students completed training at MIHS. A total of 20 foreign medical

graduates completed 20 observerships in the Department of Internal Medicine. Additionally, 56

individuals shadowed physician and nurses during the 2011-12 training year.

Graduate and Medical Residency Program

In 2011-12, MIHS employed 231 residents. In addition, integrated residency programs provided

an additional 96 residents who spent much of their training time as participants in MIHS



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allopathic training programs. The OB/GYN residency program is integrated with St. Joseph’s

Hospital and the integrated Phoenix Children’s Hospital/Maricopa Medical Center Pediatrics

training program include residents from the Med/Peds program at Banner Good Samaritan.

Residents from the pharmacy and dental programs bring the total number of MIHS trained

residents to 330.

18.8.9 Develop and Maintain Systematic Processes

MMIC will collect and analyze data from case file reviews, complaint data, utilization data,

member and stakeholder input, and grievance and appeal data to identify providers who require

additional training or technical assistance. We will use this information to identify trends in

provider performance and areas that require additional training development. We will make

additional training and technical assistance available to providers where deficiencies are

identified. When provider trends or outliers are identified, such as a specific provider

continuously experiencing difficulty in a particular area, MMIC’s Quality Management

Department may initiate a corrective action to help a provider achieve competency.

18.8.10 Training to Child Serving State Agencies

MMIC will be committed to integrating Arizona’s Twelve Principles for Children Service

Delivery and the ADHS/DBHS Arizona Children’s Vision and Principles into programs and

services that maximize the involvement of youth and families, increase resilience and improve

outcomes.

MMIC will provide training to child serving state agencies, including but not limited to the

Arizona Department of Economic Security (ADES), Arizona Department of Juvenile Corrections

(ADJC), Arizona Department of Education (ADE) and local courts. MMIC will also coach state

agency personnel in working with children and family who have behavioral health needs.



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MMIC’s qualified trainers will meet with each agency individually to assess each agency’s level

of understanding and need. Meeting with each agency individually presents the opportunity to

build strong relationships, coordinate the roles and responsibilities of MMIC and the agency, and

to tailor training plans based on each agency’s unique educational needs. Our goal is to facilitate

consistent understanding and universal application of the Twelve Principles to all children and

families through the use of Child and Family Team (CFT) practice. MMIC will work with each

child serving state agency to train staff on the nine activities that support the implementation of

the 12 Arizona Principles, including:

1. Engagement of the Child and Family

2. Immediate Crisis Stabilization

3. Strengths, Needs and Culture Diversity

4. CFT Formation/Coordination of CFT Practice

5. Behavioral Health Service Plan – Development

6. Ongoing Crisis, Planning

7. Behavioral Health Service Plan – Implementation

8. Tracking and Adapting

9. Transition

In accordance with DBHS’ Practice Protocol on Child and Family Team Practice, behavioral

health agency staff will also be required to participate in DBHS designated Child and Adolescent

Service Intensity Instrument (CASII) training, education, and technical assistance.

To help facilitate training that is convenient and easily accessible, MMIC will also make e-

learning resources available to help train state agency staff. State agency staff will have the

ability to access our course catalog, complete online courses, and request technical assistance

when needed.



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18.8.11 Education and Training for Providers on Step Therapy

MMIC will educate and train providers on step therapy and related policies and procedures in

accordance with the AHCCCS Contractor Operations Manual Chapter 400 – Operations and the

ADHS/DBHS Provider Manual Sections 3.15 Psychotropic Medication: Prescribing and

Monitoring and 4.3 Coordination of Care with AHCCCS Health Plans, Primary Care Providers

and Medicare Providers. Behavioral Health Medical Practitioners must coordinate with primary

care providers or other health care providers to minimize the potential for adverse clinical

outcomes when prescribing psychotropic medications. Additionally, we will educate behavioral

health providers that they are required to continue members who have been stabilized and are

transitioning from the RBHA to a PCP for their behavioral health needs and medications. If

clinically appropriate, the behavioral health practitioner will be required to continue medication

prescribed at the point of transition.

18.8.12 Member Service Training on GSA 6 - Geography

Our Member Services Department (within Customer Service Operations) staff will receive

comprehensive orientation and ongoing training that provides a geographic overview of GSA 6

and teaches staff to use online technology, such as mapping search engines, and to assist

members in authorizing services, recommending providers and transporting members to the most

geographically appropriate location.

18.8.13 Evidence of Staff Orientation and All Trainings

MMIC will provide specific training modules; monitor and document scheduled attendance; and

audit providers to assess compliance with required training courses. As part of the training plan,

MMIC will record evidence of employee orientation and all trainings to personnel, service

providers and members. E-learning classes will be tracked and confirmed electronically; reports



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can also be generated to verify attendance. Through the learning management system, training

activities will be tracked, including registration and completion of courses as well as

performance scores where applicable. For classroom-led training, we will use sign in sheets

record name, course duration, instructor name, date and subject of the course. For employees

who do not attend or complete training, we will notify Supervisors to take appropriate action.

18.8.14 Develop and Implement an Annual Training Plan

MMIC’s training programs, as described throughout Section 18, will serve as the basis for

developing and implementing an annual training plan. MMIC will submit an initial training

curricula and plan for approval as directed and will subsequently submit both items annually, 45

days after the close of the fiscal year.

18.8.15 Require Training Staff to Attend Quarterly Training Coordinators Meeting

MMIC will require all training staff to attend the ADHS/DBHS Quarterly Training Coordinators

Meeting.

MMIC will be committed to delivering an integrated, high-quality, consistent system of care that

fully embraces Arizona’s system values and principles. Through the experience of our sponsors,

Mercy Care Plan and Maricopa Integrated Health System, we will offer well-established training

and education programs to provide all staff, providers and stakeholders the information

necessary to fully understand the integrated delivery system and to attain the greatest benefits

from the system. By fostering collaborative relationships and encouraging active involvement,

we will incorporate input from members, family members, providers and community

stakeholders so that they have an active role in the development of training curricula and

delivery of training.



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18.21 Integrated Health Care Development Program Offeror Response:

Mercy Maricopa Integrated Care’s (MMIC) non-profit sponsors, Mercy Care Plan (MCP) and

Maricopa Integrated Health System (MIHS), have provided integrated services for more than 25

years. The experience of our sponsors have afforded us core competencies in managing

integrated health services for individuals with complex needs and excelling at integrating

physical health, behavioral health, and community-based programs for our members. Our model

is holistic and member-centric, with an emphasis on meeting the individual needs of our

members. We are focused on our members’ total health, including the interconnection between

social, cultural and environmental circumstances.

Mercy Maricopa Integrated Care (MMIC) will integrate all aspects of service delivery within our

organization including administrative, financial and clinical services. We will achieve integration

by offering: Care Coordinators to augment the existing behavioral health system; a technology

and data platform that supports the information necessary to integrate care; and through staff

expertise and resources that understand managed care delivery and the value of person-centered,

integrated care. Our model will transform the system in a way that promotes recovery, resiliency

and wellness by:

Providing recovery-oriented service delivery to members: We will do this by providing

our members with strategies and tools to achieve a progression through four phases of change

including:

Engagement: The member and primary Case Manager develop an effective working

relationship and begin the work to move the member to improved health outcomes.

Recovery: The member shows a sustained decrease in current avoidable utilization and

problematic symptoms, as well as sustained progression toward optimal quality of life

and reduction moderation of risk factors.



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Resiliency: The member decreases his/her risk of future utilization by decreasing current

risk factors and enhancing current protective factors.

Autonomy: The member takes increasing responsibility for his/her own health and well-

being, including managing his/her own health conditions effectively.

Offering robust care integration: Our care management approach will weave together

physical, behavioral health, and psychosocial support needs in a holistic manner.

Taking a holistic person-centered focus: We will focus on each member’s life goals, not

their diagnosis, while incorporating their strengths, preferences, and needs in a culturally and

linguistically appropriate manner.

Maintaining and supporting the current behavioral health system and adding supports

that strengthen it: MMIC will strengthen the existing behavioral health system with a focus

on integration by supporting the SMI Case Manager with additional resources and, by

teaching providers to deliver integrated care.

Identifying and helping provide the right service, at the right time, in the right place, at

the right level of intensity: Through data analysis and risk stratification, we will provide

care management services at varying levels of intensity, based on member strengths,

preferences, and need.

Enhancing access and coverage to services: Informed by our Care Management program,

MMIC will collaborate with network partners to increase the strength of our network to

provide access and coverage based on geographic, temporal, and physical considerations.

Enhancing member outcomes: Our Integrated Care Management approach is designed to

improve member outcomes at an individual and at a population-based level.

Supporting integrated care for members through technology and data: Through use of

technology, we will fully integrate administrative, financial, and clinical functions to support

ongoing management, monitoring, and continuous quality improvement.



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18.21.1 Establish an Integrated Health Care Program

Our Integrated Health Care Program will be an innovative and proactive approach to care. It is

designed to deliver clinical services that address the full spectrum of whole health needs –

medical, behavioral and social. It is specifically designed to support the “carved-in” integration

of medical and behavioral health services for 13,474 persons with Serious Mental Illness (SMI)

who are both AHCCCS-eligible and enrolled with the Maricopa County Regional Behavioral

Health Authority (RBHA). However, it also addresses the “carved-out” service coordination

needs of 50,523 AHCCCS eligible adults and children, and the coordination and referral needs of

21,546 people who receive NTXIX behavioral health services via the RBHA provider network

via state subvention funds. As demonstrated in Table 1 below, our integrated approach will make

a significant difference for RBHA members, who will experience many benefits as a result of

both system and member-level integration.



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Table 1: What Integrated Care WILL Look Like

System Level Member Level

X Integrated health plan functions – operations, medical management, utilization management, member services, provider services, financial

Physical and behavioral health care services provided in an integrated care setting with member choice as to the setting

X Aligned incentives Member and family-centered

X Performance measurement and shared accountability for member outcomes

Team-based care and provider engagement

X A single administrative entity that oversees both BH and PH services with shared accountability across all providers serving the members

Members are treated from a whole person perspective; ease of accessing the health plan

X Real time information exchange to support care coordination

Access to peer supports and community resources

X Risk stratification and triage to identify members with complex and co-morbid conditions who need additional support

Self-management and self-advocacy

X Dedicated commitment across providers to increase access to preventive care and reduce Emergency Department use and repeat hospitalizations

Leveraging technology for care coordination and health promotion

MMIC recognizes that a “one size fits all” approach to integrated care will not adequately and

appropriately serve the complex needs of our members with SMI. Consistent with our approach

to recovery, we believe that affording members’ choice in where and how they access health care

services is critical for engaging members in care and supporting them in their journey toward

wellness. Based on the experience of our non-profit sponsors, Mercy Care Plan (MCP) and

Maricopa Integrated Health System (MIHS), we also know that members who have an

established relationship and are comfortable with their provider are more likely to access



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preventive services, resulting in better health and well-being. We will offer our members with

SMI a choice of care coordination through three integrated/co-located health home options.

These health home models not only provide member choice but also support integration across

various settings in the provider network, as described in Table 2 below.

Table 2: Service Delivery Models Service Delivery Model Description

Whole Health Clinics Whole Health Clinics (WHC) at SMI Clinics, offer co-located PCP services, aligned incentives for integrated health outcomes.

Patient Centered Medical Homes

PCMH clinics are often operated in FQHCs or FQHC lookalikes intended to serve members in the communities in which they reside.

Care coordination in the PCMH model will occur through a practice-based Care Coordinator who facilitates ongoing communication between all providers involved in the member’s care. Clinical and non-clinical data will be shared electronically with all providers involved in the member’s care through a health information exchange to further support care coordination.

Patient Centered Health Care Home

The PCHCH model will use a wellness approach to offer members with complex needs a robust array of physical health services, and wellness education to support them in self-management.

In addition to the integrated ad co-located health home models, described above, MMIC will

support members with existing relationships with Primary Care Physicians (PCPs) to continue

receiving their physical health services with that provider. The virtual health home will allow

members who have long-standing or close relationships with their PCPs to continue to receive

physical health care services in a traditional office setting with the additional support of care

coordination tools to facilitate integration of behavioral health services in care planning and

delivery. In the virtual health home model, care coordination will be provided by MMIC

centralized care coordination function, which offers the same high touch coordination seen in

other models from a centralized location. MMIC Care Coordinators will support multiple PCP



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offices, facilitating communication between providers and supporting member health by offering

educational materials and resources.

In year one of the contract, our primary focus will be to work with each member’s clinical team

to engage the member in accessing both physical and behavioral health services. We will

establish performance goals to continuously increase the number of members with SMI

accessing physical health services. We will also work with members who have not visited a

physical health provider to establish a relationship with a co-located Whole Health Clinic

(WHC) or integrated Patient Centered Medical Home (PCMH) or Patient Centered Health Care

Home (PCHCH) health home. Members with SMI who have an existing relationship with a

physical health provider or health home will be supported in maintaining that relationship, even

if the provider is not a participant in MMIC’s network. Our Provider Services Department will

work diligently to develop contracts or single case agreements with non-participating providers

to facilitate continuity of care for each member.

Simultaneously, MMIC will work to transform the service delivery system to a fully integrated

model. Our ultimate goal is to provide fully integrated care options to all members through the

PCHCH model. We will begin the system transformation by identifying high volume PCPs that

may be interested in transforming their practice into a Patient-Centered Health Home. We will

leverage the experience of our non-profit sponsor, Mercy Care Plan (MCP), to offer providers

with the technical assistance they need to modify their practices and systems. Additionally, for

paper-based practices, we will provide technical assistance and incentives such as our Health

Information Exchange (HIE) platform free of charge to encourage providers to utilize electronic

health records (EHRs) and participate in electronic data-sharing.

MMIC will also work with our contracted Whole Health Clinics, co-located in the SMI clinics,

to assist them in moving toward a more integrated Patient Centered Medical Home, and

ultimately, Patient Centered Health Care Home model. We will provide technical assistance,



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leadership and support to each provider to assist them in their transformation efforts. Throughout

the transformation process, we will incorporate a provider pay-for-performance (P4P) program

with the goal of improving member health status, promoting the creation of health homes for our

members, increasing care coordination for all members, and reducing unnecessary utilization and

health care costs.

Additionally, MMIC will incentivize health homes to achieve accreditation through the National

Council for Quality Assurance (NCQA) to further promote quality of care. We will base our

incentive program on the MCP model, which offers incentives for health homes that achieve

level II or level III accreditation through the National Council for Quality Assurance (NCQA) or

the Utilization Review Accreditation Commission (URAC).

The Integrated Care Director will work closely with the PCMH provider to assist the practice in

achieving NCQA accreditation. Once they are ready to submit their paperwork, MMIC will

provide them with the $2500 application fee. We will also provide similar support for PCHCHs

during the Utilization Review Accreditation Commission (URAC) accreditation process.

MMIC’s timeline for system transformation, associated activities and performance targets are

outlined in Table 3 on the following page.



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Table 3: MMIC’s Timeline for System Transformation, Associated Activities and Performance Targets

Timeframe Activity

Contract Award – 3 Months Post-Contract Award

Identify all PCPs of currently enrolled persons with SMI (determine %s with PCP, PCMH, PCHCH

Identify SMI members with no PCP contact in previous 12 months

Establish integrated performance measures for BH and Primary Care Providers

Develop capitated contracts for PCPs

Develop block funding contracts for BH providers

Begin contracting with providers

3 Months Post-Contract Award –

30 Days Before Contract Start

Identify high volume PCPs for potential evolution to PCMH

Identify PCMHs for potential evolution to PCHCHs and initiate discussion

Initiate discussions with high volume PCPs appropriate for evolution to PCMH model

Complete contracts with WHCs, PCMHs, PCHCHs

Establish outreach strategies for members without PCP engagement

30 Days Before Contract Start – Contract Start

Establish PCP Panel for New Members and Member Requesting PCP changes to include WHCs/PCMHs/ PCHCHs

Contract Start – 6 Months Post Contract Start

Decrease % of members who have not received PCP services by 25%

Increase # of PCHCHs/Support WHC Evolution

Collaborative discussions of aligned incentives for future state evolution

6 -9 Months Post Contract Start

Decrease % of members who have not received PCP services by 50 %

Finalization of aligned incentives with BH and PCP providers for future state evolution

9-12 Months Post Contract Start Decrease % of members who have not received PCP services



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Timeframe Activity

by 75%

Year 2 contracting language for aligned incentives and capitation developed for WHCs and PCHCHs

New contracts ratified with WHCs and PCHCHs

12-18 Months Post Contract Start

Analysis of CY1 Integrated Performance Results

Capitated payments for WHCs and PCHCHs implemented

Continue to evolve high volume PCPs to PCMH’s and PCHCHs

Implementation of quarterly performance measures and shared aligned measures

Initiation of performance-based monitoring

Decrease % of members who have not received PCP services to no more than 5% of TXIX SMI

Majority of High Volume PCPs now PCMHs or PCHCHs

As part of our system transformation efforts, MMIC proposes to change the way services are

delivered with unprecedented care coordination between members, service providers, benefit

managers, and ADHS/DBHS. Through a unique and innovative partnership between members,

family members, physical and behavioral health providers, we will manage the resources and

provide coordinated services in an integrated system of care. Based on the experience of our

non-profit sponsors, Mercy Care Plan (MCP) and Maricopa

Integrated Health System (MIHS), we know that our care

coordination model achieves improved health outcomes and

cost savings in care delivery, utilization of services, and

maximization of existing health information technology.

The infrastructure of our Care Coordination program will be designed to integrate information

from the member’s entire multi-disciplinary care team. Our structure will not embed additional

layers into an already complex system. Instead, it will use people, processes and technology to

The PCMH model has resulted in a 7% reduction in ED visits, a 20% reduction in inpatient admissions and a 36% reduction in pharmacy costs.



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link the member to the right services, at the right time and the right place. Data, such as

periodicity information concerning preventive care, health risk assessments, the comprehensive

assessment and individual service plans, will be exchanged in near real time through our

innovative health information exchange platform to promote the state’s total population health

and health promotion goals.

In year one of the contract, we will fund Care Coordinators at the provider level for SMI clinics,

PCHCHs and PCMHs, as well as provide a centralized care coordination function at MMIC to

coordinate care for members served by PCPs or specialty providers. During the first year, we

will evaluate PCP panel sizes and volumes and work to transform the system by increasing the

number of fully integrated sites available to members. At the completion of our first year of

operation, it is our goal to transition as many MMIC employed Care Coordinators as possible to

provider sites to promote a model of care coordination that occurs as close to the member as

possible.

Care Coordinators will work with all participants involved in the treatment team to facilitate

integrated care at the member and practice level. This position is intended to augment the role of

the Case Manager and serve as a change agent to transform the service delivery system to a fully

integrated model.

Care Coordinators will work collaboratively with the member’s treatment team to provide the

necessary supports to fully integrate care. Initially, Care Coordinators will fully support the

activities of the clinical team and provide additional resources to support integration. Members

of the clinical team will provide care coordination by directly interfacing with the member on an

ongoing basis, engaging the member in access both physical and behavioral health services, and

facilitating communication as described below. In years two and three of the contract, we intend

to transform care coordination from being a specific position and move to embed these activities

into the functions of the clinical team.



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18.21.2 Support the Integrated Health Care Program to Provide Leadership in

Collaborating with Providers and System Stakeholders

MMIC’s non-profit sponsors, Mercy Care Plan (MCP) and Maricopa Integrated Health System

(MIHS), are Arizona leaders in the movement toward integrated health care service delivery.

MCP’s network providers include many models based on the patient-centered medical home.

Additionally, our sponsors have pioneered many case management and care management models

that have integrated services through active coordination. The Maricopa Integrated Health

System (MIHS) has led the state in its collaborative development of SMI and integrated family

clinic services. As the Regional Behavioral Health Authority (RBHA), MMIC will continue to

develop these services, resulting in efficiencies and effective improvements for the adult system

of care.

MMIC will build upon the relationships developed by MCP and MIHS to develop collaborative

relationships with providers and stakeholders when implementing our integrated health model.

We will actively seek out opportunities to work with other health plans, physical and behavioral

health providers, members and community stakeholders (e.g., advocates, provider associations,

government entities) to develop collaborative agreements for data sharing, program

development, and system enhancements that support integrated care.

Our SMI Services Administrator will be responsible for collaborating with providers and system

stakeholders to evaluate the behavioral health and physical health needs of persons with SMI and

determine service expansion and/or program development needs. Additionally, we will maintain

an Integrated Care Committee made up of both medical and behavioral health providers and

system stakeholders. This committee will provide input and advisement on our system

transformation efforts as well as identify and address barriers to fully integrated care. MMIC

will utilize this information to take action, including working with ADHS/DBHS and AHCCCS



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to resolve system barriers (e.g., licensure or funding issues) in addition to actively working with

system partners to promote a fully integrated system of care for members with SMI.

Behavioral Health Training – CMEs for PCPs

MMIC’s non-profit sponsor, Mercy Care Plan (MCP), identified that a large number of PCPs

lacked the training and knowledge necessary to comfortably manage the medical care of persons

with SMI. In response, MCP developed the Integrated Care Training Academy to provide

training and education to PCPs, offering Continuing Medical Education (CME) credits.

As an example, in June of 2012, 54 practitioners received training from MCP’s Medical

Director, Dr. Shelly Doumani-Semino, who is a board-certified psychiatrist. She presented on

the treatment and management of mood disorders in primary care. The program included a

discussion on “When and How to Refer for Behavioral Health Services.” The training was well-

received with 90% of the attendees citing that the learning activity met the educational objective.

The Post Training Summary Report indicates the following:

78% of the attendees felt that as a result of their training they would make changes in their

practices. They also provided a list of what that one change would be. Responses included:

“Following up more closely with BH patients.”

“Increased coordination with health plan Case Manager”

“The referral process. More contact.”

“More comfortable managing patient with d/o and with more comfort with additional

meds.”

56% of the attendees said that their major reason for attending was their interest in the topic

or an interest in the “Integrated Care” factor.

90% of the attendees requested office-based training on insomnia, pain management,

behavior modification, anti-psychotic drug reaction and Attention Deficit Hyperactivity

Disorder (ADHD).



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The degree of interest in future behavioral health trainings indicates the likelihood that ongoing

scheduled trainings serve as a strong means to improve PCP comfort level with managing

persons with SMI and retaining these providers in the network. Therefore, MMIC will offer

quarterly trainings to PCPs for CEUs in contract year one, and semi-annually thereafter. The

trainings will be determined through PCP feedback.

Approximately, 83% of training attendees indicate that they prefer site-based events to those

offered in their offices or over the web. However, in order to meet the needs of all PCPs, MMIC

will offer both. Our web-based training will be available via our website’s secure provider

portal, CEUs and will be offered by e-Learning, our vendor for web-enabled provider training.

Graduate Medical Education - Planned Enhancement to Workforce Development

Our sponsor, MCP, has worked with St. Joseph’s Medical Center’s Residency program to fill

network gaps when identified. MMIC plans to work even more closely with partners such as

Creighton University, Midwestern University, MIHS, SJMC, Arizona School of Dentistry, and

Phoenix Children’s Hospital to provide regular network development reporting to identify

specialty and geographic needs throughout MCP’s contracted Geographic Service Areas in order

to encourage development of physician capacity through GME programs. Additionally, MCP

will offer financial incentives to programs and individuals that assist in filling network gaps

through placement efforts, similar to Teach for America loan forgiveness.



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18.21.3 Develop an Integrated Health Care Report that

18.21.3.1 Describes Contractor’s Challenges, Lessons Learned, Priorities, Past Experience 18.21.3.2 Describes Contractor’s Short and Long Term Strategies 18.21.3.3 Describes Contractor’s Programs to Educate About Integrated Health Care Programs 18.21.3.4 Describes Input from Members, Providers, and System Stakeholders About Their Experiences 18.21.3.5 Approved by Contractor’s Governing Body

18.21.4 Submit the Initial Integrated Health Report to ADHS/DBHS Two Months After

Contract Performance Start Date

During implementation, our Integrated Health Administrator, Kate Rhodes, will be responsible to

develop an Integrated Health Report that complies with the requirements outlined in 18.21.3.1-

18.21.3.4. The report will be submitted to MMIC’s Governance Board for approval.

Subsequently, the report will be completed and provided to the ADHS/DBHS two months after

Contract Performance State Date and annually thereafter. Figure 1 on the following page is a

sample of the first page our Integrated Health Report.



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Figure 1: Integrated Health Report Sample (page 1)

MMIC will bring the power and passion of a mission-focused and values-driven nonprofit

organization to integrated public health care in Maricopa County. Indeed, for the past 25 years,

families and individuals have trusted our sponsors, MCP and MIHS, to deliver care for

individuals with complex needs. We will leverage this experience and expertise to develop an



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integrated care model that brings physical health and behavioral health providers together in a

shared mission to provide members with the services they need to achieve their recovery goals.

18.22 Governance Board Offeror Response:

Mercy Maricopa Integrated Care (MMIC) appreciates the importance that collaboration with a

variety of stakeholders brings to organizational governance. Persons served by the RBHA, their

families, behavioral, physical and integrated health providers, and system stakeholders all offer

valuable perspectives that can support our approach to person-centered care. Ultimately,

facilitating and continually improving the member experience will require a commitment to open

communication and decision-making focused on a true understanding of the needs of people

receiving RBHA services and their desired health outcomes. We believe that the degree of

collaboration required to attain the level of system transformation desired by ADHS/DBHS can

only be achieved by including members of all these key groups throughout our Governance

Structure.

We recognize that the effectiveness of the health care delivery system depends on its innovative

methods, dedication to collaboration and effective leadership. To that end, MMIC will design a

Governance Structure that demonstrates our process transparency, focus on shared decision-

making and our passion to achieve the best outcomes possible for the people we serve. We will

use data to drive innovative organizational decisions while we maintain the checks and balances

necessary for RBHA oversight. Our Governance Structure’s processes and actions will foster

collaboration with members, families, providers and system stakeholders, as well as coordination

with ADHS/DBHS.

Our governance model will contribute to the transformation of a bifurcated system of care into a

fully integrated model in multiple ways, including the following:

Advising and monitoring the status of implementation activities and milestones



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Acting on information and advice from stakeholder committee members representing all

populations served programs offered by the RBHA

Overseeing establishment of best practices to promote integration and quality services across

systems of care

Reviewing the implementation of Pay for Performance measures, per member/ per month

(PM/PM) premiums and aligned incentive programs for high-functioning provider groups

Monitoring measures of performance, and member and provider satisfaction

18.22.1 Governance Board Structure

Mercy Maricopa Integrated Care (MMIC)’s Governance Structure includes both a Board of

Directors (the Board) and a Governance Committee, each with peers and family members

representing at least 25 percent of voting membership. We strongly believe the voice of peers

and families must be heard throughout all levels of our Governance Structure. Therefore, peers

and families will also participate in committees reporting to the Governance Committee.

Our recruitment of peers and family members for participation on the Board and other

committees will comprise an open process designed to promote transparency, accountability,

regional participation and collaboration. During implementation, we will invite people receiving

services through the RBHA and their families to submit a letter of interest (LOI) to be members

of the Board. Our Individual and Family Affairs Administrator will make recommendations to

the Governance Committee based on those LOIs that demonstrate the strongest philosophical

alignment with the MMIC mission statement. Membership tenure of these committees will be

limited to two years, to increase exposure to the Board by more peers and their families.

Our Governance Structure is illustrated by Figure 1 on the following page.



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Figure 1: MMIC Governance Committee Structure

In the paragraphs that follow, we detail the Governance Structure and the responsibilities of each

of its committees.

MMIC Board of Directors

(Meets 6 times per year, more frequently during implementation)

As a non-profit entity, our Board of Directors will be the governing body with ultimate oversight

of MMIC. The Board is responsible for establishing policies and objectives in alignment with

ADHS/DBHS transformational objectives, as well as the vision of MMIC in alignment with the

Adult and Child System of Care principles espoused by ADHS/DBHS. The Board will assess

the availability of adequate financial resources and oversee performance for the GSA 6 Regional

Behavioral Health Authority (RBHA). Twenty-five percent of its membership will consist of



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peers and family members who are, or have, been active participants in the Maricopa County

Behavioral Health System.

MMIC’s Board will also include members from its sponsoring organizations, Mercy Care Plan

(MCP) and Maricopa Integrated Health System (MIHS). MCP is sponsored by Dignity Health

(d.b.a. St Joseph’s Hospital and Medical Center), and Carondelet Health Network, a ministry of

Ascension Health. These organizations will also be represented on MMIC’s Board.

Immediately after award, during contract implementation, MMIC will establish its Board of

Director’s bylaws, structure and leadership, as well as its reporting committees.

Committees reporting to the MMIC Board of Directors

Two committees will report directly to MMIC’s Board of Directors – the Governance and

Executive Committees. They will be designed to support the Board’s strategic direction to

oversee the transformation of RBHA. These committees will be heavily invested during

implementation and transition, meeting as often as necessary to make policy, programmatic and

operational changes in collaboration with ADHS/DBHS and AHCCCS. The Board will

empower them to expediently act upon implementation concerns addressed by members, families

and system stakeholders. These committees are described in Table 1 on the following page.



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Table 1: Committees Reporting to the MMIC Board of Directors Name Frequency Description/Activities Attendees

Governance Committee

Six times per year, more frequently during implementation, until successful transition

Carry out strategic direction of the Board

Central decision-making mechanism for the contract, and the avenue through which concerns about the program are systematically addressed,

Review of contract performance

Receives feedback from all other committees to evaluate contract performance

Review and determination of community reinvestment opportunities.

Twenty-five percent (25%) of the membership will be equal representation between peers and family members who are currently in the system or have been active participants

Behavioral and physical health care community providers

System and community stakeholders

Representatives from sponsoring organizations and MMIC management

Executive Committee


Decisions regarding stewardship of the RBHA’s funding

Oversight of the RBHA’s adherence to ADHS/DBHS Financial Reporting Guide

Review of financial, auditing and compliance reports and activities

Oversight of management services administrator

Chair of the MMIC Board of Directors

Co-Chair of the MMIC Board of Directors,

Chief Financial Officer (CFO) of Carondelet, St. Joseph’s, and MIHS

Chief Executive Officer of MMIC

MMIC CFO, CMO and COO

Representatives from sponsoring organizations and MMIC management



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Subcommittees of MMIC Governance Committee

Five committees will report to the Governance Committee. They include Integrated Care and

Quality Management, Advocacy, CLAS, Youth Leadership and Implementation.

Each will have targeted responsibilities that are aligned to provide the Governance Committee an

overall picture of the RBHA’s effectiveness in meeting its mission and ADHS/DBHS directives.

These committees will provide feedback and recommendations on the status and needs at both

the system and population level. All populations served by the RBHA will be represented in

these committees, as illustrated in Table 2 below and on the following pages.

Table 2: Subcommittees of MMIC Governance Committee Name Frequency Description/Activities Attendees

Integrated Clinical Care and Quality Management Committee


Integrate clinical care and quality activities throughout the organization, among its departments, contractors, and stakeholders

Oversee clinical and quality activities

Make recommendations to the Governance Committee

Peers and family members

Community-based behavioral and physical health provider agencies

Representatives from the Board of Directors of MMIC

MMIC management team as invited and select subcommittee members



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Name Frequency Description/Activities Attendees

Member Advocacy Committee (Referred to as Advocacy Committee)

Once per month Advise, assist, and give guidance to MMIC related to clinical programs, and the service delivery system

Provide input and feedback on behavioral health programs

Determine effectiveness of adult and child system of care in improving the whole health of those served by the system

Collaborate with ADHS/DBHS and system stakeholders for changes and improvements when necessary


Community and behavioral health advocates

Communications / Public Relations Administrator

Director of Stakeholder Collaboration

Chaired by the Individual and Family Affairs Administrator

Make recommendations to the Governance Committee

Youth Leadership Council

Once per month Provide a forum for youth to provide leadership and input into the behavioral health system

Review program development and enhancements needed to promote recovery and resiliency in children, youth, and families

Determine mechanisms and supports necessary to penetrate services into at-risk youth populations

Make recommendations to the MMIC Governance Committee

Youth currently receiving services through the RBHA who are between the ages of 14-26

Chaired by the Transitional Youth Coordinator.



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Culturally and Linguistically Appropriate Services (CLAS) Committee

Once per month Oversee the network’s adherence to CLAS standards

Establish initiatives to reduce health disparities

Determine outreach strategies needed to increase service penetration into at-risk populations

Makes recommendations to the MMIC Governance Committee


Community advocates representatives

Representatives include specialty providers serving high percentages of at-risk, underserved populations

Cultural Sensitivity Administrator

Chaired by the CEO through CY1 and Co-Chaired

by the Cultural Sensitivity Administrator in subsequent years

Implementation Committee

Weekly during Implementation through successful transition then sunsets

Review implementation plan and its tracking of milestones

Provide pulse of community regarding implementation activities

Identify revisions necessary to achieve vision of MMIC

Make recommendations to the MMIC Governance Committee


Peer- and family-run Provider Organizations

Adult, Child and Crisis Behavioral Health Providers

Integrated Health providers

MMIC Executives Chaired by the Chief

Operating Officer



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Subcommittees of the Integrated Clinical Care and Quality Management Committee

The subcommittees of the Integrated Clinical Care and Quality Management Committees will

provide essential feed-back and recommendations on the RBHA’s quality, medical and

utilization management operations and outcomes. These subcommittees are described in Table 3

on the following pages. The committee will use that information for recommendations of

emerging innovations, resources and tools necessary to support evolution of system

transformation and outcomes.



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Table 3: Subcommittees of the Integrated Clinical Care and Quality Management Committee


Quality Management Committee

Meets once per month

Evaluation of quality improvement activities, and performance measurement data

Establish recommendations for improvement of member care and services.

Review and approve studies, standards, clinical guidelines, and trends identified in measured outcomes and results of provider medical record reviews and satisfaction surveys

Make recommendations to the Integrated Clinical Care and Quality Management Committee


Representatives from Integrated Health, Behavioral Health, community providers and peer- and family-run organizations

Deputy Medical Officer, Medical Management

Administrator Quality Management

Administrator Integrated Health Care

Development Administrator, Management,

Chief Clinical Officer Select subcommittee

members and support staff.

Chaired by the CMO



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Continuous Innovation Committee


Identify cutting edge solutions and best practices to improve programs, processes, and systems

Research and evaluate emerging innovations, resources, and tools that provide value to member care and services



Representatives from Integrated Health, Behavioral Health, community providers and Peer- and family-run organizations

CMO Deputy Medical Officer Medical Management

Administrator Chief Clinical Officer Adult Services

Administrator Children’s Services

Administrator Children’s Service

Medical Administrator Select subcommittee

members

Medical Management/

Utilization Management Committee


Evaluate new technologies Utilization management

decisions Clinical review criteria for

approval, adoption, and implementation

Review and make recommendations for performance improvement activities related to trends in complaints, grievances and appeals, quality of care concerns as well as a result of provider medical record reviews and satisfaction surveys




Deputy Medical Officer Medical Management Administrator

Quality Management Administrator

Integrated Health Care Development Administrator

Chief Clinical Officer Chaired by the CMO



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Subcommittees of the Quality Management Committee

The subcommittees of the Quality Management Committee – described in Table 4 on the

following pages – will provide essential feedback and recommendations on all Quality activities

of the RBHA. They will provide relevant information needed to develop a global view of the

status of RBHA’s Quality functions, improvement activities and outcomes. These committees

will provide the CEO, CMO, and Quality Management Administrator with data necessary to

determine strategies and enhancements needed to promote system evolution and the whole health

of persons served by the RBHA.



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Table 4: Subcommittees of the Quality Management Committee Name Frequency Description/Activities Attendees

Quality Improvement Committee (QIC)

Meets bi-weekly

Advises the Chief Medical Officer and Chief Operating Officer on quality improvement strategies

Oversees compliance with AHCCCS, ADHS/DBHS and Medicare quality improvement strategies

Responsible for oversight of Performance Improvement Projects, AHCCCS, ADHS/DBHS performance measures, HEDIS, member and provider satisfaction surveys, health literacy, cultural competency, member grievances, and service performance measures

Members and family members

Representatives from Integrated Health, Behavioral Health, community providers and peer- and family- run organizations

Chief Clinical Officer Deputy Medical Officer Medical Management


Administrator Integrated Health

Network Administrator Medicare Administrator Adult Services

Administrator Children’s Services

Administrator Children’s Medical

Administrator Customer Service

Administrator, Select subcommittee

members Chaired by the CMO



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Delegation Oversight Committee

Meets quarterly, and as needed during implementation’

Advise and make recommendations about issues related to delegated entities

Evaluate reports stemming from sub-contractor audits

Review all subcontractors’ performance for adherence to their contracts


Representatives from Integrated Health, Behavioral Health, community providers and peer- and family- run organizations

Chief Operating Officer Vice President of

Operations Network Development

Administrator Chief Compliance

Officer Contract Compliance

Administrator Additional Subject

Matter Experts

Credentialing/Re-credentialing Committee

Meets monthly Evaluate credentialing and re-credentialing information to recommend selection, approval, or denial of healthcare providers for participation in the network

Review policies related to credentialing/

re-credentialing and analyzes health facility site reviews and medical record reviews

Representatives from Integrated Health, Behavioral Health, community providers


Network Development Administrator

Credentialing Manager Medical Management

Administrator Chaired by CMO



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Adult QM Committee

Meets six times per year, more frequently as needed in implementation

Evaluate quality improvement activities

Examine performance measurement data to provide recommendations related to the services provided to adults with a serious mental illness and adults with a general mental health/substance abuse issue.

Review the results of provider medical record reviews,

Evaluate fidelity audits (ACT, supported employment, consumer operated services, and peer support) and satisfaction surveys



System stakeholder organizations


Credentialing Manager Adult Services

Administrator SMI Services

Administrator General Mental

Health/Substance Abuse Administrator

Prevention Administrator

Crisis Administrator Medical Management


Administrator Individual and Family

Affairs Administrator Children’s Services

Administrator Deputy Medical Officer Chaired by the CMO



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Children’s QM Committee

Meets six times per year, and more frequently as needed during implementation

Evaluate quality improvement activities

Examine performance measurement data to provide recommendations related to the services provided to children including those with CMDP and SED

Review the results of Child and Family Team audits, provider medical record reviews, fidelity and satisfaction surveys

Family members Representatives from

children’s providers, peer- and family-run organizations

System stakeholder representatives

Network Development Administrator – Children’s Supervisor

Credentialing Manager Children’s Services

Administrator Children’s Medical

Administrator Crisis Administrator Medical Management


Administrator Adult Services

Administrator Individual and Family

Affairs Administrator Chaired by the CMO

Peer Review

Meets quarterly Make recommendations to the Chief Medical Officer related to actions to be taken in response to quality of care reviews and investigations related to specific providers

Present findings to the Credentialing /Re-credentialing Committee for consideration/actions

Representatives from Integrated Health, Behavioral Health, community providers

Medical Management Administrator


Deputy Medical Officer Integrated Health

Development Officer Subcommittee

members and support staff

Chaired by the CMO



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Subcommittees of the Medical Management Committee

The subcommittees of the Medical Management Committee – described in Table 5 on the

following pages – will provide essential feedback and recommendations on all Medical

Management activities of the RBHA. They will provide the relevant information needed to

develop a global view of the status of RBHA’s medical management trending of behavioral and

physical health services across all populations. Along with the committees reporting to the

Quality Management Committees, these subcommittees of Medical Management will provide

the CEO, CMO, and Quality Management Administrator with the data necessary to determine

strategies and enhancements needed to promote evolution of the system and the whole health of

persons served by the RBHA.



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Table 5: Subcommittees of the Medical Management Committee Name Frequency Description/Activities Attendees

Utilization Management Intra-Department Committee

Meets monthly Identify and establish utilization targets and goals

Review trends in complaints, grievances and appeals, potential quality of care issues

Evaluate trends in utilization and develop initiatives to make improvements to internal processes

Peer and family members

Representatives from Adult and Children’s, Integrated Health providers, and peer- and family- run organizations

Medical Management Administrator

Deputy Medical Officer UM Administrator Adult Services


Administrator Chief Clinical Officer Prior Authorization

Manager Crisis Administrator Grievance System

Administrator General Mental Health

and Substance Abuse Administrator

Children’s Medical Administrator

Children’s Services Administrator

Integrated Health Care Administrator


Chaired by CMO



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Pharmacy and Therapeutics (P&T)

Meets four times a year

Advise and make recommendations regarding MMIC’s pharmacy program

Developing/update the MMIC Preferred Drug List

Review drug utilization data

Evaluate member and provider educational programs

Evaluate new technology related to pharmacy and reviews information related to contracted pharmacy services

Peer and family members

Representatives from Adult and Children’s, Integrated Health providers, and peer- and family-run organizations

Representatives from PBM

CMO Deputy Medical Officer Chief Clinical Officer Children’s Medical

Administrator MMIC internal staff Chaired by Pharmacy

Administrator

Member Advisory Committee (MAC)

Meets monthly Provide recommendations to the Medical Management/Utilization Management and Quality Management Committees on a variety of activities, communications, program interventions, and service

Review outreach plans, cultural competency plans, and education materials to assess content and readability

Provide advice on performance improvement and quality improvement projects

Responsible for oversight and review of prevention programs and satisfaction survey tools


Member Advocates Communications/ Public Relations

Administrator Customer Services

Administrator Representatives from

functional departments Chaired by Individual

and Family Services Administrator



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Subcommittees of the Continuous Innovation Committee

These committees and their membership – described in Table 6 below and on the following

pages – will support MMIC’s collaboration with adult and child behavioral health and crisis

providers. It will also promote our evolutionary care coordination program by including

integrated health, physical health and Serious Mental Illness clinic providers. The Continuous

Innovation Committee will use information obtained during work group meetings to identify

cutting-edge solutions and best practices to improve programs, processes and systems; research

and evaluate emerging innovations, resources and tools that provide value to member care and

services; and make recommendations to the Integrated Clinical Care and Quality Management

Committee.

Table 6: Subcommittees of the Continuous Innovation Committee Name Frequency Description/Activities Attendees

Adult Provider Workgroup

Meets six times per year, more frequently as needed in implementation

Bring providers together to share ideas and success stories related to innovative clinical practices

Provide training and education about new initiatives.

Opportunity for providers to network, communicate, facilitate real-time discussions, and bring up issues or concerns

Monitor clinical outcomes and make recommendations for changes in pay for performance initiatives and aligned incentives


Representatives from Integrated Health, Behavioral Health, Crisis, community providers, and peer- and family-run organizations

Deputy Medical Officer SMI Services

Administrator Chief Clinical Officer General Mental Health

and Substance Abuse Administrator

Crisis Administrator Chaired by Adult

Services Administrator



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Children’s Provider Workgroup

Meets 6 times a year

Bring providers together to share ideas and success stories related to innovative clinical practices

Provide training and education about new initiatives

Opportunity for providers to network, communicate, facilitate real-time discussions, and bring up issues or concerns

Monitor clinical outcomes and make recommendations for changes in pay for performance initiatives and aligned incentives

Peers/youth and family members

Representatives from children’s providers, peer- and family-run organizations

Chief Clinical Officer Children’s Medical Crisis Administrator Chaired by Children’s

Services Administrator

Provider Integration Group

Meets 6 times a year

Review member-specific cases to identify and resolve systemic issues related to integration of care

Make recommendations to overcome cultural barriers and promote consistency in practices across all providers

Monitor clinical outcomes and make recommendations for changes in Pay for Performance initiatives and aligned incentives


Representatives from Adult and Children’s providers, Integrated Health, Crisis Providers, and peer-and family-run organizations

Deputy Medical Officer Chief Clinical Officer Adult Services

Administrator Tribal Liaison Cultural Sensitivity


Administrator Chaired by the

Integrated Health Development Officer



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Subcommittees of the Executive Committee

These subcommittees will provide the necessary information for the Executive Committee to use

to oversee MMIC’s audit and compliance functions in support of legal and regulatory

requirements, as well as quality of care and ethical business practices. They will also review the

financial detail used for budgeting purposes and stewardship of the RBHA.

Table 7: Subcommittees of the Executive Committee Name Frequency Description/Activities Attendees

Audit & Compliance Committee

Meets six times per year and as needed during implementation

Overseeing MMIC’s audit and compliance functions in support of legal and regulatory requirements, as well as quality of care and ethical business practices

Review, monitor and promote compliance with the organization’s policies, procedures and practices

Executive Committee Members

CEO COO Corporate Compliance

Administrator CMO CFO

Finance Committee

Meets monthly Continuously review and make recommendations for improvement, where needed, concerning the organization’s fiscal affairs

Provide recommendations to the Executive Committee on the annual budget and business plan

Executive Committee Members

CEO COO CMO Corporate Compliance

Administrator CFO

18.22.2 No Contractor Staff as Peer or Family Representatives on Governance Board

Mercy Maricopa Integrated Care (MMIC) will not have employees serve as peer and family

member representatives on its Board of Directors (the Board) or Governance Committee. They

will include members from Mercy Care Plan (MCP) sponsors, Carondelet Health Network, St.

Joseph’s Health System, and Maricopa Integrated Health System (MIHS). The Board and

Governance Committee will include an equal number of peers and family members who are



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active or past participants in the Maricopa Behavioral Health System, and will comprise no less

than 25 percent of the governing membership.

Mercy Maricopa Integrated Care’s (MMIC) Governance Structure will be based on, and

facilitate, meaningful collaboration with persons served by the RBHA, their family members,

behavioral and physical health providers, and system stakeholders. We believe that the evolution

from the current bifurcated system of behavioral and physical health services to an integrated

model, as desired by ADHS/DBHS, can only be achieved by the inclusion of these groups

throughout our Governance Structure. Our Board of Directors, committees and structural

reporting lines will enable thorough oversight of RBHA activities and the alignment of

organizational goals necessary to drive dramatic, sustainable improvements in health care

outcomes. The composition of our Board will rely on strong leadership with strong community

ties, and will incorporate the perspectives of various stakeholders to afford true transparency.

18.23 Offshore Performance of Work Prohibition When responding, include Offeror’s intent to comply. Offeror Response:

Mercy Maricopa Integrated Care (MMIC) will comply with the Scope of Work 18.23.1

requirement to perform all contract services within the defined territories of the United States.

This will include work related to indirect or “overhead” services, redundant/back-up services or

services that are incidental to the performance of the contract.



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