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SoonerCare Physician Assistant Contract 2005 Revised October 2004 OKLAHOMA HEALTH CARE AUTHORITY SOONERCARE PHYSICIAN ASSISTANT CONTRACT YEAR 2005 This Contract is made this ___________ day of _________________________, 20___, by and between Oklahoma Health Care Authority and ___________________________________________________ [Name of Contractor] ___________________________________________________ [Address of Contractor] ___________________________________________________ [City] [State] [Zip] Physician Assistant License #___________________________ Social Security # ___________________________ To offer his/her services to the Oklahoma Health Care Authority, hereinafter referred to as “OHCA”, Contractor must fully complete and execute this contract, then return the original to: SoonerCare Program Attn: Contractor Services Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105
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Page 1: OKLAHOMA HEALTH CARE AUTHORITYokhca.org/provider/contracts/soonercare/pdflib/scc_physicianassista… · 2.3-Access to Care 12 2.4-Emergency Services and Post-Stabilization Care Services

SoonerCare Physician Assistant Contract 2005 Revised October 2004

OKLAHOMA HEALTH CARE AUTHORITY SOONERCARE PHYSICIAN ASSISTANT

CONTRACT YEAR 2005

This Contract is made this ___________ day of _________________________, 20___, by and between

Oklahoma Health Care Authority and

___________________________________________________

[Name of Contractor]

___________________________________________________

[Address of Contractor]

___________________________________________________

[City] [State] [Zip]

Physician Assistant License #___________________________

Social Security # ___________________________

To offer his/her services to the Oklahoma Health Care Authority, hereinafter referred to as “OHCA”,

Contractor must fully complete and execute this contract, then return the original to:

SoonerCare Program Attn: Contractor Services

Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124

Oklahoma City, OK 73105

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SoonerCare i Physician Assistant Contract 2005 Revised October 2004

TABLE OF CONTENTS Page Number

Article 1-Introduction 1.0-SoonerCare Program Overview 1 1.1-General Program Information 1 1.2–Definitions 2 Article 2-Contractor Qualifications 2.1-Licenses and Permits 8 2.2-Contractor Responsibilities and Services Provided 10 2.3-Access to Care 12 2.4-Emergency Services and Post-Stabilization Care Services 13 2.5-Early and Periodic Screening, Diagnosis and Treatment (EPSDT) 13 2.6-Administrative Responsibility 14 2.7-Record Keeping and Reporting 15 2.8-Confidentiality of Records 15 2.9-Compliance with HIPAA Requirements 16 2.10- Marketing Activities 16 Article 3-Member Enrollment 3.1-Selecting PCP/CM 17 3.2-Non-Discrimination 17 Article 4-Member Disenrollment 4.1-Continuity of Care 18 4.2-Determination of Disenrollment 18 4.3-Disenrollment at Request of PCP/CM With Cause 18 4.4-Disenrollment at Request of Member With Cause 20 4.5-Disenrollment at Request of Member Without Cause 20 4.6-Disenrollment by Order of the OHCA 20 4.7-Automatic Re-enrollment 20 Article 5-Payments and Reimbursements 5.1 - Base Capitation Payment 20 5.2 - Case Management Payment 21 5.3 - Reimbursement for Emergency Room Services 21 5.4 - Supplemental Payment for Lock-in Members 21 5.5 - EPSDT Bonus Payment 22 5.6 - EPSDT Safety Net Providers 22 5.7 - Immunization Payments 23 5.8 - Supplemental Payment for Immunization 23 5.9 - Stop-Loss 24 5.10- Payment Adjustments 24

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SoonerCare ii Physician Assistant Contract 2005 Revised October 2004

Page Number

Article 6-Obligations of the OHCA 6.1-Administrative Responsibilities 24 6.2-Conflict of Interest 26 6.3-Nurse Advice Line 27 6.4-Access to Women’s Health Specialist 27 Article 7-Member Rights 7.1-Member Rights and Protection 27 Article 8- General Terms and Conditions 8.1-Contract Period and Renewal 28 8.2-Termination 28 8.3-Compliance with All Applicable Laws and Regulations 29 8.4-Compliance with Specific Laws and Regulations 29 8.5-Grievance and Appeal Procedures 31 8.6-Waivers 31 8.7-Assignment of the Contract 32 8.8-Hold Harmless 32 8.9-Notices 32 8.10-Severance 33 8.11-Modifications 33 8.12-Incorporation by Reference 33 8.13-Choice of Law 33 8.14-Venue 33 8.15-Miscellaneous Reimbursement Requirements 33 8.16-Attestation 34 Affidavit 35 Attachments Attachment A-Capitated Benefit Section 36 Attachment B-PCP/CM Application/Credentialing Form 40 Attachment C-Monthly Rate Schedule 49 Attachment D-Electronic Funds Transfer Authorization 50 Attachment E-Recommended Childhood Immunization Schedule 51 Attachment F-Early & Periodic Screening Diagnosis and Treatment Periodicity Schedule 52 Attachment G-Addendum II EPSDT Screening & Notification Document 53 Attachment H-Addendum IX EPSDT Confirmation Form 54 Attachment I-CY 2005-2007 EPSDT Bonus Payment Methodology 55 Attachment J-Disclosure of Ownership and Control Interest Statement 56

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SoonerCare 1 Physician Assistant Contract 2005 Revised October 2004

ARTICLE 1: INTRODUCTION 1.0 SOONERCARE PROGRAM OVERVIEW

The State of Oklahoma operates a Medicaid Program to provide health care for persons eligible under 42 U.S.C. §1396 et seq. Under 42 U.S.C. §1315(a) waiver authority from the Federal government, Oklahoma operates a mandatory managed care program known as SoonerCare for a portion of its Medicaid population. The Oklahoma Health Care Authority (OHCA) operates a Primary Care Case Management (PCCM) system hereinafter referred to as "SoonerCare" for eligible individuals. The State’s objectives for SoonerCare include the following: A. To improve access to medical care, including preventive services, primary care

and early prenatal care for Oklahoma’s Medicaid population. B. To ensure that every Medicaid beneficiary is able to choose a primary care

provider who will serve as his/her provider and be responsible for providing all basic medical services.

C. To better integrate Medicaid beneficiaries with the privately insured population,

through enrollment into managed care delivery systems serving both populations.

D. To instill a greater degree of budget predictability into the Oklahoma Medicaid

program, by moving from a Fee-For-Service (FFS) system to one based on the concept of pre-payment.

SoonerCare is under the administrative control of the Oklahoma Health Care Authority-the State designated Medicaid agency. The program is also overseen by the Centers for Medicare and Medicaid Services (CMS).

1.1 GENERAL PROGRAM INFORMATION

The SoonerCare program enrolls Medicaid recipients with primary care providers/case managers (PCP/CMs) who provide and/or authorize all primary care services and all necessary specialty services, with the exception of services for which authorization is not required. In exchange for a fixed, periodic rate, which is paid per member per month, the PCP/CM provides or otherwise assures the delivery of medically necessary primary care and case management services included in the benefit package contained in Attachment A, and referrals for specialty services for an enrolled group of eligible individuals. The PCP/CM assists the client in gaining access to the health care system and monitors the client's condition, health care needs and service delivery. A. Services that do not require a referral from the PCP/CM include:

(1) behavioral health services, (2) vision services, (3) dental services,

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SoonerCare 2 Physician Assistant Contract 2005 Revised October 2004

(4) child abuse/sexual abuse examinations, (5) prenatal and obstetrical services and supplies, (6) family planning services, (7) women’s routine and preventive health care services, (8) emergency services, and (9) specialty care for members with special health care needs (as defined

by the OHCA). Non-capitated Medicaid covered services delivered by the PCP/CM are reimbursed at the Medicaid FFS rate under the procedure code established for each individual service. To the extent services are provided or authorized by the PCP/CM, the agency does not make Medicaid payments for services delivered outside the scope of coverage of the Medicaid program, thus a referral by the PCP/CM does not guarantee payment.

1.2 DEFINITIONS

The terms used in this contract have the following meanings: A. ACCESS means a patient’s ability to obtain medical care, as determined by

the availability of medical services and their acceptability to the patient, the location of facilities, transportation, hours of operation and cost.

B. ACTION means a termination, suspension or reduction (which includes

denial of a service based on the Office of General Counsel's interpretation of CFR 431) of Medicaid eligibility or covered services.

C. ADVANCE DIRECTIVE means a document in which an individual gives

instructions about their health care if, in the future, they cannot speak for themselves. An “agent” or “proxy” is given the power to make health care decisions (the kind of health care wanted/not wanted) for the individual.

D. AGED, BLIND & DISABLED (ABD) is a category of Medicaid eligibility

based upon age, medical diagnosis and disability status 42 U.S.C. Section 1396a(a)(10)(A)(I) and (f), excluding those persons eligible for both Medicaid and Medicare, or currently institutionalized, or in state custody or served through a Home and Community Based Waiver, such as the ADvantage Waiver.

E. APPEAL is an expression of dissatisfaction reflected by a request for review

of an Action.

F. AUTHORITY means the Oklahoma Health Care Authority (OHCA).

G. CAPITATION means a contractual arrangement through which the Contractor agrees to provide specified health care services to enrollees for a specified prospective payment per member, per month.

H. CASE MANAGEMENT means, but is not limited to:

1. providing direct health care to patients including necessary EPSDT screenings and immunizations;

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SoonerCare 3 Physician Assistant Contract 2005 Revised October 2004

2. providing medically necessary specialty referrals, including standing referrals;

3. coordinating admissions to hospital; 4. making appropriate referrals to the Women, Infants and Children (WIC)

program; 5. coordinating and monitoring all family centered medical care on behalf of

a member; 6. coordinating with community mental health professionals; and/or 7. educating patients to appropriately use medical resources such as

emergency room and Nurse Advice Line.

I. CMS means Centers for Medicare and Medicaid Services (the agency formerly known as HCFA)

J. CLIENT means a recipient, member, enrollee or beneficiary. K. CONTRACT YEAR 2005 means January 2005 through December 2005.

L. COLD CALL MARKETING means any unsolicited personal contact by the

Contractor with a potential member for the purpose of marketing. M. COMPLAINT see GRIEVANCE. N. CONTRACTOR means a PCP/CM that serves eligible SoonerCare members

pursuant to this contract. O. COVERED POPULATIONS means:

1. The population covered under the “Temporary Assistance for Needy

Families” (TANF) programs, 42 U.S.C. §601 et seq., as provided by 42 U.S.C. §1396a(a)(10)(A)(i) and (f);

2. Pregnant women and children qualified under 42 U.S.C. §1396d(n); 3. The populations known as Aged, Blind and Disabled, 42 U.S.C.

§1396a(a)(10)(A)(i) and (f), excluding those persons dually-eligible for Medicaid and Medicare, or currently institutionalized, or in state custody, or served through a Home and Community Based Waiver, such as the ADvantage waiver;

4. The persons eligible under 56 O.S. Supp. 1999, §1010.1; and 5. The SoonerCare population, which are groups of other eligibles resulting

from federal or state mandated categories of eligible persons.

P. CO-PAYMENT means any enrollment fee, premium, deductible, coinsurance, co-payment or any other similar charge that imposes a cost-sharing requirement upon the recipient.

Q. CREDENTIALING means the review of qualifications and other relevant

information pertaining to a health care professional who seeks appointment (in the case of an organization directly employing health care professionals) or who seeks a contract with the organization. (Quality Improvement System for Managed Care -QISMC- 3.5.1.1).

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SoonerCare 4 Physician Assistant Contract 2005 Revised October 2004

R. EMERGENCY MEDICAL CONDITION means a medical condition

manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected, by a prudent layperson, to result in:

1. placing the health of the individual (or, with a pregnant woman, the health

of her unborn child) in serious jeopardy, or 2. serious impairment to any bodily functions; or 3. serious dysfunction of any body organ or part. 4. with respect to a pregnant woman who is having contractions: inadequate time to effect a safe transfer to another hospital before

delivery or transfer may pose a threat to the health or safety of the woman or the unborn child.

S. EMERGENCY SERVICES means covered inpatient and outpatient services

that are furnished by a provider that is qualified to furnish these services and that are needed to evaluate or stabilize an emergency medical condition.

T. ENCOUNTER DATA means the record of a health-care related service

rendered by a provider to a member who is properly enrolled in SoonerCare on the date of service.

U. ENCOUNTER DATA CLAIM means the submission of encounter data for

any single health-care related service for any individual properly enrolled in SoonerCare.

V. ENROLLEE see MEMBER.

W. EPSDT/ Early and Periodic Screening, Diagnosis and Treatment means

a program defined by 42 U.S.C. §1396a(a)(43) and d(r) which covers screening and diagnostic services for enrollees under the age of 21 to determine physical and mental defects and to ascertain health care treatment and other measures to correct or ameliorate any defects and chronic conditions discovered.

X. EPSDT OUTREACH means, but is not limited to, a telephone call or printed

notification mailed to a recipient/member when a health care screening is indicated or missed.

Y. FAMILY PLANNING SERVICES means an office visit for a comprehensive

family planning evaluation, including obtaining a pap smear. Family planning services do not include a pathologist’s lab fee.

Z. FEE-FOR-SERVICE CONTRACT means a contract offered by the OHCA

that compensates a provider according to a fee schedule for each Medicaid compensable service delivered to a Medicaid eligible recipient.

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SoonerCare 5 Physician Assistant Contract 2005 Revised October 2004

AA. FOLLOW-UP or FOLLOW-UP SERVICES FOR EPSDT means all medically necessary services which are a result of the EPSDT screening performed on the member under the age of twenty one (21).

BB. GRIEVANCE means an oral or written expression of dissatisfaction about

any matter other than an Action as defined in this section. The term is also used to refer to the overall system that includes grievances and appeals handled by the OHCA and access to the State fair hearing process.

CC. HCFA means Health Care Financing Administration. See CMS.

DD. HIPAA means Health Insurance Portability and Accountability Act of 1996 EE. IHS means Indian Health Service. FF. INSTITUTIONALIZED means residing in a nursing facility, long term care

facility, or State-run public facility. It also refers to enrollment in a waiver program designed to provide services outside of nursing or long term facilities, such as the Home and Community Based Waiver, Intermediate Care Facility/Mentally Retarded Waiver, the Alternative Disposition Plan waiver, or the ADvantage Waiver.

GG. LONG TERM INSTITUTIONAL CARE means Medicaid recipients receiving

medical care in nursing facilities, or intermediate care facilities for the mentally retarded (ICF/MR).

HH. MARKETING means any communication from a PCP/CM to a Medicaid

recipient who is not enrolled with the PCP/CM, which can reasonably be interpreted as intended to influence the recipient either to enroll with that particular PCP/CM, or not to enroll, or to disenroll from another PCP/CM.

II. MARKETING ACTIVITIES means any communication from a PCP/CM to a

Medicaid recipient directly or indirectly whether door-to-door, telephone, or other cold-call means.

JJ. MARKETING MATERIALS means materials that are produced in any medium,

by or on behalf of a PCP/CM that can reasonably be interpreted as intended to market to potential members.

KK. MEDICAID means the medical assistance program authorized by 42 U.S.C.

§1396a et seq. The program provides medical benefits for certain low-income persons. It is jointly administered by the Federal and state governments.

LL. MEDICALLY NECESSARY SERVICES means covered medical, dental,

behavioral, rehabilitative or other health care services which:

1. are reasonable and necessary to prevent illness or medical conditions, or provide early screening, interventions, and/or treatment for conditions that cause suffering or pain, cause physical deformity or limitation in function, cause illness or infirmity, endanger life, or worsen a disability;

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SoonerCare 6 Physician Assistant Contract 2005 Revised October 2004

2. are provided at appropriate facilities and at the appropriate levels of care for the treatment of a member's medical conditions;

3. are consistent with the diagnoses of the conditions; and 4. are no more intrusive or restrictive than necessary to provide a proper

balance of safety, effectiveness, efficiency and independence and will assist the individual to achieve or maintain maximum functional

capacity in performing daily activities, taking into account both the functional capacity of the individual, and those functional capacities that are appropriate for individuals of the same age; and are age and gender appropriate.

MM. MEMBER means a Medicaid eligible person who is enrolled with a

Contractor. This term is used interchangeably with the terms enrollee, patient, recipient, and beneficiary. Excluded are those persons eligible for both Medicaid and Medicare, or currently institutionalized, or in state custody or served through a Home and Community Based Waiver such as the ADvantage Waiver.

NN. OBSTETRICAL SERVICES means prenatal care, delivery and sixty (60)

days of postpartum care. OO. OSIIS means Oklahoma State Health Department Immunization Information

System. PP. PANEL means a group of recipients who have selected a provider for health

care as part of the Medicaid program. QQ. PATIENT see MEMBER. RR. PCP/CM means primary care provider/case manager. SS. PHYSICIAN means a partnership, limited partnership, limited liability

company, corporation, professional corporation composed of doctors of medicine and/or doctors of osteopathy and/or advanced nurse practitioner and/or physician assistants who provide health care of the nature provided by independent practitioners and is permitted by State and Federal law and regulations to receive Medicaid provider payments.

TT. PMPM means per member per month. UU. POST STABILIZATION SERVICES means covered services, related to an

emergency medical condition that are provided after an enrollee is stabilized in order to maintain the stabilized condition, or, under the circumstances described in 42 CFR 438.114(e) to improve or resolve the enrollee’s condition.

VV. POTENTIAL MEMBER means a Medicaid recipient who is subject to

mandatory enrollment or may voluntarily elect to enroll in a given managed care program, but is not yet a member of a specific PCP/CM.

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SoonerCare 7 Physician Assistant Contract 2005 Revised October 2004

WW. PREVENTIVE CARE means the treatment to avert disease, illness or their consequences. There are three levels of preventive care; primary, such as immunizations, aimed at preventing disease; secondary, such as disease screening programs aimed at early detection of disease; and tertiary, such as rehabilitative therapy, aimed at preventing deterioration in function after the disease has occurred.

XX. PRIMARY CARE SERVICES means all services listed in Attachment A to

this contract.

YY. PROVIDER means a partnership, limited partnership, limited liability company, corporation, professional corporation composed of doctors of medicine and/or doctors of osteopathy and/or advanced nurse practitioners and/or physician assistants who provide health care of the nature provided by independent practitioners and is permitted by State and Federal law and regulations to receive Medicaid provider payments.

ZZ. QUALITY ASSURANCE means the formal set of activities to assure a

standard of quality of services provided. Quality assurance includes assessment and corrective actions taken to remedy and identify deficiencies. Comprehensive quality assurance includes mechanisms to ensure the quality of health care, administrative and support services.

AAA. QUALITY OF CARE means the degree or grade of excellence with respect to medical services received by enrollees, administered by providers or programs, in terms of technical competence, need, appropriateness, acceptability, humanity, structure, etc.

BBB. RATE CATEGORY means a specific age-sex cell per group. See

Attachment C.

CCC. RECIPIENT see MEMBER. DDD. REFERRAL means a referral from a PCP/CM for a member needing to

access a specialist for a specified frequency or number of visits.

EEE. SOONERCARE means Oklahoma’s Medicaid managed care program.

FFF. STANDING REFERRAL means a referral from a PCP/CM for a member needing to access multiple appointments with the specialist over a set period of time (such as a year), without seeking multiple referrals. This may include a limitation on the frequency or number of visits.

GGG. STATE means the State of Oklahoma. HHH. STOP-LOSS means a payment by the OHCA triggered by a monetary

threshold above which the OHCA will contribute part or all the costs of medical care.

III. TANF means Temporary Aid to Needy Families.

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SoonerCare 8 Physician Assistant Contract 2005 Revised October 2004

JJJ. TIMELY SUBMISSION OF ENCOUNTER CLAIMS means claims filed within 60 days of the date of service. KKK. TITLE XXI means the Program defined at 42 U.S.C. §2101 et. seq. LLL. URGENT MEDICAL CONDITION means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain,

psychiatric disturbances and/or symptoms of substance abuse), such that a reasonably prudent lay person could expect that the absence of medical attention within twenty-four (24) hours could result in:

1. placing the health of the individual (or with respect to a pregnant woman the

health of the woman or her unborn child) in serious jeopardy; or 2. serious impairment to bodily function; or 3. a serious dysfunction of any body organ or part.

MMM. UTILIZATION means rate patterns of service usage or types of service occurring within a specific time. Utilization is generally expressed in rates per

unit of population-at-risk for a given period; e.g., the number of office visits to a PCP/CM over 1,000 member months.

NNN. VISION SERVICES means examinations and refractive services provided by

optometrists or ophthalmologists, within the legal scope of their practice.

ARTICLE 2: CONTRACTOR QUALIFICATIONS 2.1 Licenses and Permits A. The Provider (hereinafter referred to as “Contractor”) states: 1. He/she is a person who provides health care services as defined in the Physician Assistant Act (59 O.S. Supp. 1997 §519.2(3) (or as the law of the State where the Contractor is located, if in a State other than Oklahoma); is duly licensed as a physician assistant as required by 59 O.S. Supp. 1997 §519.4 (or the law of the State where the Contractor is located, if in a State other than Oklahoma);.

2. He/she is in good standing with licensing authorities; and has all other state, federal, tribal, and local licenses and permits required for the conduct of such practice. All such licenses and permits shall be kept current during the term of this contract. 3. Contractor’s supervising physician fulfills the statutory and regulatory

requirements to serve as a supervising physician of a physician assistant and shall actively supervise the Contractor in a manner consistent with the Oklahoma Physician Assistant Act, the requirements of the supervising physician’s licensing agency and professional practice.

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SoonerCare 9 Physician Assistant Contract 2005 Revised October 2004

B. The Contractor states:

1. He/she has a current Fee-for-Service (FFS) Medicaid contract and provider number. The Medicaid contract provides that each contractor shall have a unique identifier as soon as that system is operational.

2. He/she has not been sanctioned by the Federal government or any State government for program violations in the Medicare or Medicaid program. 3. He/she is a physician assistant who meets all requirements for

employment by the Federal government as an assistant to a physician.

C. The Contractor agrees that he/she will meet any applicable credentialing standards adopted by the OHCA. The failure to be credentialed during

any part of the term of this agreement shall immediately render the contract void.

D. The Contractor shall carry medical malpractice insurance in the amount of no

less than one million dollars ($1,000,000.00) per occurrence, unless all hospitals at which he/she has staff privileges require less; in which case he/she must carry insurance at the level of the most restrictive hospital requirement. A physician, physician assistant, or nurse practitioner covered by the Federal or State Tort Claims Act is exempt from this requirement. The OHCA reserves the right to require the Contractor to provide documentation of medical licensure and insurance coverage.

E. The Contractor shall comply with 42 C.F.R. §1001.101 and 1001.201et seq.,

which provides that the Contractor shall not use the services of any Contractor who has been suspended, barred, or excluded from Medicaid, Medicare, S-CHIP or any other federal grant program, unless the Contractor has been reinstated pursuant to law. Federal Financial Participation (FFP) is not available for amounts expended for excluded providers. Violation of this paragraph at the contract’s execution or during any part of the term of the contract shall immediately render the contract void.

F. The Contractor may not knowingly have a relationship with the following:

1. An individual who is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued under Executive Order No. 12549.

2. An individual who is an affiliate, as defined in the Federal Acquisition Regulation, of a person described as above.

3. A relationship includes the following: a. a director, an officer, or a partner of the PCP/CM.

b. a person with beneficial ownership of five percent or more of the PCP/CM's equity.

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SoonerCare 10 Physician Assistant Contract 2005 Revised October 2004

c. a person with an employment, consulting or other arrangements with the PCP/CM under the contract with the OHCA.

2.2 Contractor Responsibilities and Services Provided

A. In addition to case management services, the Contractor shall provide all capitated services as contained in Attachment A for adults and children without payment in addition to the capitation rate except as otherwise provided in this contract. The Contractor shall also ensure that the services provided are sufficient in amount, duration, or scope to reasonably meet the health care needs of the members assigned to the provider.

The Contractor shall not arbitrarily deny or reduce the amount duration, or scope of a required service solely because of the diagnosis, type of illness, or condition. However, the Contractor may place appropriate limits on a service on the basis of criteria such as medical necessity; or for utilization control, provided the services furnished can reasonably be expected to achieve their purpose. The Contractor shall report any suspected fraud and abuse information to the OHCA. Any other services in the benefit package which cannot be provided by the Contractor in the Contractor’s office must be purchased by the Contractor from another provider without payment in addition to the capitation rate except as otherwise provided in this contract.

B. The Contractor shall submit claim forms for all services provided to

SoonerCare members in the same manner and on the same forms as are used to submit claims for all other Medicaid recipients. Encounter claims shall be submitted within 60 days of the date of service. Denied claims shall be corrected and resubmitted within 60 days of adjudication.

C. The Contractor shall provide medically necessary services for all recipients

enrolled with the Contractor. The Contractor may not exclude recipients enrolled with the Contractor for treatment because they are new, or have not previously been seen by the Contractor, or have an outstanding balance, except when the Contractor has dismissed the member prior to their SoonerCare enrollment.

D. The Contractor is not responsible for providing referrals for obstetrical, vision

for refraction, dental, behavioral health services, family planning services, specialty care for members with special health care needs, women’s routine and preventive health care services or medically necessary services rendered in an emergency setting. The Contractor, may, upon request, refer a member to a qualified Oklahoma Medicaid contracted health care provider for a second opinion.

E. The Contractor is not responsible for making a referral for services delivered to

American Indians at IHS, Tribal, or urban Indian clinics.

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SoonerCare 11 Physician Assistant Contract 2005 Revised October 2004

F. The Contractor shall develop and enforce policies and procedures in accordance with laws regarding communicable diseases. These policies and procedures shall include universal precautions, including precautions related to Human Immuno-Deficiency Virus (HIV) serologically positive patients. The Contractor shall educate employees and members with regard to HIV and its related conditions including Acquired Immuno-Deficiency Syndrome (AIDS).

G. The Contractor shall comply with 42 U.S.C. §§1395cc(f), 1396a(a), and 1396a(w), which require, in part, Medicaid Contractors to provide patients with information about patients’ rights to accept or refuse medical treatment. The Contractor shall maintain written policies and procedures for Advance Directives, and shall educate his/her staff and adult Medicaid recipients concerning advance directives (living wills). The Contractor shall provide adult enrollees with written information on Advance Directives policies, and include a description of applicable State law. The written information provided by the Contractor must reflect changes in State law as soon as possible, but no later than 90 days after the effective date of the change. The Contractor shall include in each patient’s individual medical record documentation as to whether the patient has executed an Advance Directive.

H. The Contractor shall not charge a co-payment or for missed appointments to

SoonerCare members when the Contractor serves as the PCP/CM for the member. The Contractor shall not seek payment or reimbursement from a member for all or part of the cost of a covered service.

I. Data, information and reports collected or prepared by Contractor in the course of performing its duties and obligations under the contract shall be deemed to

be owned by the State of Oklahoma. This provision is made in consideration of Contractor's use of public funds in collecting or preparing such data, information and reports.

J. The Contractor shall ensure that its laboratory testing site providing services

under this contract has either a CLIA certificate or waiver of a certificate of registration along with a CLIA identification number.

K. The Contractor shall submit the PCP/CM Application and Credential form

(Attachment B). Each individual provider shall complete the OHCA’s credentialing process.

L. The Contractor shall submit written notification to the OHCA at any time there is

a change in the number or composition of providers (physicians, physician assistants, nurse practitioners, etc.).

M. In the event the OHCA changes services, benefits, geographic service area or

payments, the Contractor shall implement all policy changes in conformance with the requirements of the OHCA.

N. The Contractor shall be accountable for any functions and responsibilities that it

delegates to any subcontractor. The Contractor must also have a written agreement between it and the subcontractor that specifies the activities and report responsibilities delegated to the subcontractor.

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SoonerCare 12 Physician Assistant Contract 2005 Revised October 2004

O. The Contractor must ensure that it monitors the subcontractor’s performance on an ongoing basis and subject it to formal review according to a periodic schedule established by the OHCA, consistent with industry standards and State regulations. P. The Contractor must provide that its Medicaid members are not held liable for: 1. the Contractor’s debts, in the event of its insolvency. 2. covered services provided to the member, for which the State does not pay

the Contractor. 3. covered services provided to the member, for which the State does not pay

the health care provider who furnishes the services under a contractual, referral or other arrangement.

4. payments for covered services under a contractual, sub-contractual, referral or other arrangement, to the extent that those payments are in excess of the amount that the enrollee would owe if the Contractor provided the services directly.

Q. In the event of insolvency, the Contractor must continue to provide services to members for the duration of the period for which payment has been made by

the OHCA.

2.3 Access to Care

The Contractor shall: A. Ensure the availability of twenty-four (24) hour per day, seven (7) days per

week, telephone coverage which will immediately page an on-call medical professional. The Contractor shall provide the OHCA evidence of the number. The Contractor shall provide all enrolled members in his/her panel with the information necessary to access the 24-hour coverage. The Contractor is authorized to use the OHCA’s Nurse Advice Line toll-free number as a resource to fulfill the after hours telephone coverage requirement.

B. Comply with Federal and State standards regarding access and quality of care.

The Contractor agrees to cooperate with the OHCA’s external quality of care review organization and its Medicaid Director with regard to utilization reviews conducted and other quality assurance efforts.

C. Make a medical evaluation of the member or cause such an evaluation to be

made: 1. within twenty-four (24) hours with appropriate treatment and follow up as deemed medically necessary for those members with an urgent medical condition. 2. available within three (3) weeks for non-urgent medical problems. This

standard does not apply to appointments for routine physical exams, nor for regularly scheduled visits to monitor a chronic medical condition, if that condition calls for visits to occur less frequently than once every three weeks.

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D. Offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the Contractor serves only Medicaid members.

2.4 Emergency Services and Post-Stabilization Care Services

A. The Contractor is not required under this contract to authorize, refer or provide emergency services or treatment of members who present at hospital emergency rooms. The emergency room is intended for evaluation and treatment of medically necessary emergency conditions. It is not appropriate for providers to refer patients to the emergency room for non-emergency conditions. Medical care for non-emergency medical conditions shall be provided in the office setting. In order to encourage appropriate continuity of care, Contractors shall advise members of the proper use of the emergency room. The OHCA will monitor emergency room services for appropriate use by members and Contractors.

B. The Contractor shall not require members to seek prior authorization for

services in a medical emergency. Nothing in this paragraph shall limit the Contractor’s provision of these services to an enrolled member consistent with his/her legal scope of practice services to the member in an emergency room setting.

C. In the event the Contractor provides emergency care in an emergency room

setting to an enrolled member consistent with the Contractor’s legal scope of practice, the OHCA shall reimburse the Contractor the schedule rates set by the OHCA for medically appropriate services.

D. The Contractor may not limit what constitutes an emergency medical condition

on the basis of lists of diagnoses or symptoms. E. The Contractor may not hold the member liable for payment of subsequent

screening and treatment needed to diagnose the specific condition or stabilize the patient.

F. In the event the Contractor provides emergency care in an emergency room,

the Contractor is responsible for determining when the enrollee is sufficiently stabilized for transfer or discharge.

2.5 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) A. The Contractor shall comply with the OHCA requirements regarding periodicity

of EPSDT screenings and services, and shall make EPSDT a priority in his/her health care for recipients under the age of twenty-one (21).

The Contractor shall: 1. Schedule the following EPSDT appointments for all recipients under the

age of twenty-one (21); a. Six (6) visits during the first year of life; b. Two (2) visits in the second year of life; c. One (1) visit yearly for ages two (2) through five (5);

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d. One (1) visit every other year for ages six (6) through twenty (20); 2. Conduct and document follow ups with all members under the age of 21 who have missed appointments;

3. Conduct and document EPSDT outreach to ensure that members under the age of twenty-one (21) are current with respect to the periodicity

schedule in 2.5A(1); and

4. Educate families who have members under the age of twenty-one (21) about the EPSDT Program and its importance to the health of children and adolescents.

B. In addition, for the services rendered in 2.5(A) above, the OHCA shall pay an

annual EPSDT bonus payment, as described in Article 5.6, when the Contractor achieves a sixty-five percent (65%) or higher annual compliance rate with the appointments described in Article 2.5(A)(1) for Calendar Year 2005.

C. The OHCA has designated school-based clinics and local health departments

as “safety net” providers for EPSDT screenings. See Article 5.7 “Safety Net EPSDT” for details on payments to safety net providers.

D. An EPSDT screening must consist of the following five elements to be counted

as a completed screen:

1. Comprehensive Health and Development Assessment: including Assessment of both physical and mental development;

2. Complete Physical Examination: physical growth and unclothed physical inspection;

3. Immunizations: age appropriate immunizations (any contraindicated

immunizations may be given in a follow-up exam);

4. Health Education/Anticipatory Guidance; and 5. Appropriate Lab Tests: such as anemia, sickle cell test, tuberculin test.

Blood lead testing is required at 12 months and 24 months of age and up to 72 months if not previously screened.

2.6 Administrative Responsibility

The Contractor shall: A. Report to the OHCA or its designated Sub-Contractor any member status

changes such as births, deaths, marriages, and changes of residence, in a timely manner, when known. The Contractor shall provide this information to SoonerCare at 1-800-987-7767.

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B. Obtain proper consent and transfer member medical records free of charge, if requested, in the event that the member moves or changes PCP/CMs.

C. Report to the OHCA, in writing, any changes in personal banking information, including address, telephone number, facility, hours, etc., at least ten (10) business days prior to the effective date of such change.

2.7 Record Keeping and Reporting The Contractor shall:

A. Provide encounter data to the OHCA on state-defined claim forms within sixty (60) days of the date of service. The Contractor shall correct and resubmit denied encounters within sixty (60) days. The Contractor shall submit other data as requested by the OHCA which would support research studies by the OHCA.

B. Establish and maintain a unified medical record for each member that is

consistent with the OHCA’s regulations and current professional standards. The records shall document all care provided by or through the Contractor.

C. Document in the member’s medical record each referral to other health care

providers. The Contractor shall also keep a copy of each medical report(s) submitted to the Contractor by the health care provider for each member referral. If a medical report is not returned, the Contractor will contact the health care provider to whom the referral was made to obtain such report(s).

D. Coordinate and record referrals made to “safety net providers” based under the EPSDT program.

E. Maintain such records as are necessary, to disclose fully the extent of services

provided to recipients under this contract and to furnish information regarding any FFS payments claimed for providing services under the State Medicaid Plan. The Contractor shall keep records of services delivered to adult recipients served under this contract for six (6) years after the OHCA makes final payment and all other pending matters are closed. The Contractor shall keep records of services delivered to minors for two (2) years plus the age of majority, but in no event less than six (6) years.

F. Allow the OHCA, other appropriate entities, the US Secretary of Health and Human Services, the US Comptroller General or representatives, the Oklahoma State Auditor and Inspector and the Medicaid Fraud Control Unit of the Oklahoma Attorney General’s Office the right to examine the Contractor’s, or its subcontractor’s, books, financial and medical records, documents, accounting procedures, practices or any other items relevant to this contract pursuant to 74 Okla. Stat. §85.41(E).

2.8 Confidentiality of Records

A. The Contractor agrees that all information, records and data collected in connection with the contract shall be protected from unauthorized disclosures.

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SoonerCare 16 Physician Assistant Contract 2005 Revised October 2004

In addition, the Contractor agrees to guard the confidentiality of member information.

B. Access to identifying information shall be limited by the Contractor to persons

or agencies which require the information in order to perform their duties in accordance with this agreement, including the OHCA, the US Department of Health and Human Services, the Medicaid Fraud Unit of the Office of the Oklahoma Attorney General and other individuals or entities as may be required by the OHCA.

C. Any other party shall be granted access to confidential information only after complying with the requirements of State and Federal laws and regulations pertaining to such access. The OHCA shall have absolute power to determine if and when any other party has properly obtained the right to have access to this confidential information. Nothing herein shall prohibit the disclosure of information in summary, statistical, or any other form that does not identify particular individuals. The Contractor shall retain the right to use information for its Quality Assessment, Utilization Review and other research purposes subject to the data ownership and publicity requirements defined within the contract.

D. The Contractor shall agree to keep all records, information and data collected

in connection with the services provided under this contract confidential. The Contractor shall inform all employees of this confidentiality requirement. Access to confidential information shall be limited to persons or agencies which require the information in order to assist in the administration of Oklahoma's Medicaid Plan. This specifically includes, but is not limited to, the OHCA, the US Department of Health and Human Services, and the Medicaid Fraud Control Unit of the Oklahoma Attorney General's office. In the event a subpoena is served upon the Contractor for member records, the Contractor shall immediately notify the OHCA prior to the release of the records so that legal action may be taken to protect the confidentiality of the records.

2.9 Compliance with HIPAA Requirements (Privacy and Confidentiality)

The Contractor shall abide by the following rules on privacy and confidentiality of health information: the federal privacy regulations and the federal security regulations as contained in 45 C.F.R. Part 160-164 that are applicable to such party as mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. § 1320d through 1320d-8 and 45 C.F.R. § 160.101 et seq.

2.10 Marketing Activities The Contractor shall:

A. Assure the OHCA that marketing, including plans and materials, is accurate and does not mislead, confuse, or defraud the members or the OHCA.

B. Distribute the materials to its entire service area as defined by the OHCA. C. Not distribute marketing materials without first obtaining written approval from

the OHCA.

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SoonerCare 17 Physician Assistant Contract 2005 Revised October 2004

D. Not seek to influence enrollment in conjunction with the sale or offering of any

private insurance. E. Not directly, or indirectly, engage in door-to-door, telephone, or other cold-call

marketing activities.

ARTICLE 3: MEMBER ENROLLMENT 3.1 Selecting PCP/CM

A. The OHCA shall offer all recipients the opportunity to choose an appropriate PCP/CM from a directory of available PCP/CMs. Families with more than one member will be allowed to choose a different PCP/CM for each family member. If the potential member does not voluntarily select a PCP/CM timely, the OHCA will assign the member to a Contractor based on time/distance standards.

B. The OHCA shall inform the Contractor of his/her new enrollees and any

terminations to the existing roster prior to the first day of each month.

C. The Contractor shall specify a capacity of Medicaid members he/she is willing to accept under this contract. The maximum capacity is one thousand two hundred fifty (1,250) for a full-time SoonerCare Contractor.

D. The OHCA does not guarantee the Contractor an enrollment level nor will the

OHCA pay for members who are not eligible or excluded from enrollment.

E. The Contractor has no proprietary interest in SoonerCare members assigned to his/her panel, assigned to another PCP/CM’s panel, or eligible for any Medicaid program.

F. The Contractor may request a change in his/her capacity by submitting a

written request to the SoonerCare program. This request is subject to review according to program standards. In the event the Contractor requests a lower capacity, the OHCA may lower the capacity by disenrolling members to achieve that number or allowing the capacity to adjust as members change their PCP/CM or lose eligibility.

3.2 Non-discrimination

Unless approved by the OHCA, Contractor must accept individuals in the order in which they apply without restriction up to the capacity established by the contract. Contractor may not refuse an assignment or will not discriminate against individuals eligible to enroll on the basis of health status or need for health care services or on the basis of race, color or national origin. Contractor will not use any policy or practice that has the effect of discriminating on the basis of race, color or national origin.

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ARTICLE 4: MEMBER DISENROLLMENT

4.1 Continuity of Care

For any change in PCP/CM, the Contractor shall provide medically necessary health care for any member who has selected or been assigned to the Contractor, until the OHCA officially reassigns the member. The effective date of change shall be set so as to avoid the issue of provider abandonment. The Contractor shall not notify the member of a change until the Contractor has received notification from the OHCA.

4.2 Determination of Disenrollment The OHCA shall act upon all disenrollment requests within 30 days of receipt by the SoonerCare program. A member can be disenrolled from the Contractor for any of the following reasons: A. The member has filed and prevailed in an appeal regarding quality of care

issues, or other matters deemed sufficient to warrant disenrollment. B. The member has moved out of the SoonerCare service area and address

change has been verified by DHS.

C. The member has been enrolled in error, as determined by the OHCA. This includes, but is not limited to, dual eligibility, state custody, private HMO coverage, institutionalization or enrollment in a waiver program. The disenrollment will be effective on the date of exclusion from managed care.

D. The member requires specialized care for a chronic condition and the OHCA,

member, member’s PCP/CM and the receiving PCP/CM agree that the assignment to the receiving PCP/CM is in the member’s best interest.

E. The member has been dismissed previously by PCP/CM prior to enrollment with

that PCP/CM and documentation of the dismissal is provided to the OHCA.

F. If the OHCA fails to make the determination within the timeframes specified in 4.2, the disenrollment is considered approved.

4.3 Disenrollment At Request of PCP/CM With Cause

A. The PCP/CM may file a written request asking the State to take action including, but not limited to, disenrolling a member when the member is physically or verbally abusive (threatening) to office staff, providers and/or other patients and the PCP/CM has made all reasonable efforts to accommodate the member or when the member is “habitually non-compliant” (i.e. regularly fails to arrive for scheduled appointments without canceling, and the PCP/CM has made all reasonable efforts to accommodate the member).

PCP/CM may not request disenrollment because of a change in the member's

health status, or because of the member's utilization of medical services,

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SoonerCare 19 Physician Assistant Contract 2005 Revised October 2004

diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs (except when his or her continued enrollment with the PCP/CM seriously impairs the PCP/CM's ability to furnish services to either this particular member or others).

B. The PCP/CM must document all efforts taken to inform the member, both orally

and in writing, of any actions that have interfered with the effective provision of covered services, as well as explain the following:

1. What actions or language of the member are acceptable and what is unacceptable;

2. The consequences of such continued behavior, including the PCP/CM filing a request to seek disenrollment; and 3. The potential disenrollment from the PCP/CM.

In all instances, the PCP/CM must seek member disenrollment through filing a written request to the OHCA directed to the SoonerCare Program. This request must include comprehensive documentation describing the difficulty encountered with the member (i.e. nature, extent and frequency of abusive or harmful behavior, violence, and/or inability to treat or engage enrollee), identification and documentation of unique religious or cultural issues that may be affecting the PCP/CM’s ability to provide treatment effectively to the member, as well as documentation of special assistance or intervention offered.

C. The State will give written notice of the disenrollment request to the member. D. Should the Contractor request a disenrollment with cause, the OHCA shall act

upon the request within thirty (30) days of receipt by the SoonerCare program.

E. In the event the disenrollment request is approved, the OHCA will disenroll the member from the SoonerCare program and enroll the member in the FFS program through the end of the contract year to ensure continuity of care, unless another PCP/CM within the time/distance standard agrees to accept the member for enrollment to ensure continuity of care. In this instance, the OHCA will provide notices to the Contractor as well as the member.

F. The member will not be enrolled with the same PCP/CM again, unless the

PCP/CM agrees to the enrollment in writing.

G. The OHCA’s decision is at its sole discretion, subject to appeal under its grievance policy. Either party has the right to appeal the decision to the Administrative Law Judge pursuant to OAC 317:2-1-2 (the OHCA’s Grievance Procedure).

H. If the OHCA fails to make the determination within the timeframes specified in

4.2, the disenrollment is considered approved.

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SoonerCare 20 Physician Assistant Contract 2005 Revised October 2004

4.4 Disenrollment At Request Of Member With Cause

A. A member may request disenrollment for cause at any time.

B. The member (or his or her representative) must submit an oral or written request to the OHCA (or its agent).

C. Regardless of the procedures followed, the effective date of an approved

disenrollment must be no later than the first day of the second month following the month in which the member files the request.

D. If the OHCA fails to make the determination within the timeframes specified in

4.2, the disenrollment is considered approved. 4.5 Disenrollment At Request Of Member Without Cause

A. Following the date of the member’s initial enrollment with the PCP/CM or the date the OHCA sends the member notice of the enrollment, whichever is later, the member may request additional PCP/CM changes without cause up to a maximum of four (4) times per year total.

B. If the member seeks disenrollment from the Contractor to another PCP/CM and

has exhausted their right to change PCP/CMs without cause up to four times a year, the member must follow the Agency's grievance process. If approved, the disenrollment will take effect in accordance with the time frames specified in 4.4C.

C. If the OHCA fails to make the determination within the timeframes specified in 4.2, the disenrollment is considered approved.

4.6 Disenrollment By Order of the OHCA

The OHCA has the responsibility of disenrollment of members from the PCP/CM if the OHCA terminates the PCP/CM contract or if the Contractor terminates his/her participation in the SoonerCare program.

4.7 Automatic Re-enrollment

The OHCA provides automatic re-enrollment of a member who is disenrolled solely because he or she loses Medicaid eligibility for a period of 180 days.

ARTICLE 5: PAYMENTS AND REIMBURSEMENTS 5.1 Base Capitation Payment

A. The OHCA shall pay the Contractor a capitated rate for each member enrolled with the Contractor based on the rate schedule in Attachment C to this contract.

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SoonerCare 21 Physician Assistant Contract 2005 Revised October 2004

B. The capitation paid is for all primary care services and preventive services listed in Attachment A.

C. The OHCA shall make capitation payments by the tenth business day of each

month. Payment may be made by electronic direct deposit to the bank and account designated by the Contractor. The Contractor shall be responsible for the accuracy of direct deposit information provided to the OHCA and for updating such information in writing as needed. A single capitation amount will represent payment for all eligible members enrolled with the Contractor as of the first day of that month. The Contractor will receive a single payment derived by multiplying the number of his/her SoonerCare members in the several rate categories by the rate amounts for those categories. This payment will be made for all enrolled recipients, regardless of what, if any, covered services the Contractor renders during the month.

D. In the event the Vaccines for Children (VFC) program is eliminated or if covered

vaccines are not available, the OHCA shall either adjust the capitation payment or modify the contract to allow Fee-For-Service (FFS) reimbursement for the purchase of the vaccine.

5.2 Case Management Payment

The OHCA includes a case management payment along with the base capitation rate paid to the Contractor per member, per month, as shown in Attachment C.

5.3 Reimbursement for Emergency Room Services

Emergency medical condition services are not part of the capitation rate. If the service can be provided within the Contractor’s scope of practice, the physician may provide the services and be reimbursed at the current Medicaid fee schedule, if provided in the emergency room.

5.4 Supplemental Payment for Lock-in Members

On review of paid Medicaid claims, it may be determined that a member has had an unusually high number of visits to more than one Contractor. In this event, a member may be placed in a “lock-in” program. A lock-in member must choose one Contractor to coordinate the member’s health care needs. The chosen Contractor must provide additional medication counseling including pharmaceutical use and the potential misuse. The Contractor shall collaborate with other providers to ensure compliance of the SoonerCare program guidelines by the member. For those lock-in members enrolled with the Contractor, the OHCA shall pay an additional $3.00 per member/per month as provided in Article 5.1. Semi-annual payments will be computed based on the number of lock-in member enrollments during the periods of January 1 through June 30 and July 1 through December 31. The OHCA will process payment under this Article no later than August 31 and February 28.

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5.5 EPSDT Bonus Payment OHCA has a total of $1,000,000.00 annually for the purpose of EPSDT bonus payments. If the total amount of bonus payments is $1,000,000.00 or less, each Contractor that achieves an appropriate compliance rate as specified in Article 5.6 (A), will be paid accordingly, however, should the total amount of bonus payments exceed $1,000,000.00, the bonuses will be pro-rated and paid accordingly (see Attachment I – Methodology Example). The OHCA shall make this additional payment in a lump sum within one hundred eighty (180) days after the end of the contract year. The Contractor’s actual compliance rate will be based upon encounter data submitted to the OHCA no later than March 1 and corrected no later than May 1 of each year. An annual EPSDT bonus payment will not exceed 20% of the Contractor’s annual capitation payment for SoonerCare. In addition to payments described in 2.5 (B) and (C), the OHCA shall make a payment to the Contractor only if he/she: A. For Contract Year 2005, has achieved a sixty-five percent (65%) or better

compliance level for EPSDT screenings for twelve (12) months as reflected by the periodicity schedule in 2.5 (A). Compliance is subject to an on-site chart audit after review of the encounter data submitted to the OHCA by the Contractor.

B. Demonstrates that medically necessary follow-up services were provided or

appropriate referrals for follow-up were made. C. Demonstrates that he/she has outreach mechanisms in place to encourage

members to obtain appropriate screenings.

5.6 EPSDT Safety Net Providers EPSDT screening by providers other than the PCP/CM may occur under the conditions described below: A. If the provider is a school-based clinic, clinic staff must contact the PCP/CM for

screening and/or prescription information when required under State law for Early Intervention services. Clinic staff must complete Attachment G, Addendum II EPSDT Screening & Notification Document for each contact. The PCP/CM must respond with a screening appointment within three (3) weeks. If the PCP/CM is unable or unwilling to provide a screening within the three (3) week time frame, the clinic may provide the screening and bill as fee-for-service. When the local health department clinic intends to perform an EPSDT screening on a child, the PCP/CM will receive a copy of the Attachment G, Addendum II form within twenty-one (21) days of the screening. The addendum will serve as notice of intent to bill for the screening. In all cases, when a screening is provided to a child, the results must be provided to the PCP/CM. The clinic staff will also inform PCP/CM by means of the Addendum II form of any child in the clinic’s district who has an urgent need for an EPSDT screening within a given school year.

B. If the provider is a local health department clinic, clinic staff must contact the

PCP/CM for screening and/or prescription information when required under

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SoonerCare 23 Physician Assistant Contract 2005 Revised October 2004

State law for Early Intervention services. Clinic staff must complete an Attachment H, Addendum IX EPSDT Confirmation Form (Schedule G & H) for each contact. The PCP/CM must respond with a screening appointment within three (3) weeks. If the PCP/CM is unable or unwilling to provide a screening within the time frame, the clinic may provide the screening and bill FFS. When the local health department clinic intends to perform an EPSDT screening on a child, the PCP/CM will receive a copy of the Addendum IX form within twenty-one (21) days of the screening. The addendum will serve as notice of intent to bill for the screening. In all cases, when a screening is provided to a child, the results must be provided to the PCP/CM within ten (10) days after the screening.

C. The Contractor may obtain most of the immunizations listed in the capitated

package for children at no cost to the Contractor by participation in the Vaccines For Children (VFC) Program through the Oklahoma State Department of Health. Failure to provide vaccines, under certain circumstances, may result in recoupment of funds from the Contractor.

D. The Contractor must provide adults with the tetanus, pneumococcal, hepatitis A,

hepatitis B and influenza vaccines when medically necessary.

5.7 Immunization Payments

Vaccine administration fees have been included in the capitation rate schedule. Under Federal and State law, the State is prohibited from paying twice for the same service. The cost for SoonerCare members receiving immunizations from other providers authorized to bill the OHCA for these services is considered in the annual actuarial certification process for setting capitation rates.

5.8 Supplemental Payment for Immunization

The OHCA shall pay the Contractor a supplemental payment of $3.00 for each member who is immunized with the fourth (4th) dose of DPT/DTaP before the member’s second birthday. The OHCA will process an annual payment for the period January 1 through December 31. Contractor must submit member lists no later than March 31 of each year. The member list shall include the name of each qualified member, the Recipient Identification number and the date of the fourth DTaP immunization. Payments will be made to the Contractor upon verification by the OHCA that the member is on the Contractor’s panel on the date the immunization is administered and an encounter claim has been successfully submitted.

OHCA has a total of $50,000.00 annually for these payments. If the total amount of payments is $50,000.00 or less, each contractor will be paid accordingly. However, should the total amount exceed $50,000.00 the payments will be pro-rated and paid accordingly.

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SoonerCare 24 Physician Assistant Contract 2005 Revised October 2004

5.9 Stop-Loss

In the event the FFS equivalent costs of capitated services performed by the contractor in this contract year exceeds $1,800.00 annually for a single enrolled member, the OHCA shall pay ninety percent (90%) of all covered services performed by the contractor for the member after this threshold is reached on a FFS basis. The contractor who believes this threshold is reached must notify the OHCA by contacting the provider representative in writing with the member’s name and recipient identification number. The threshold is determined by only the services rendered by a single provider or a single group. The value of services rendered by one provider for a particular member during a contract year cannot be added to a succeeding or preceding provider’s rendered services to determine the threshold. The $1,800.00 threshold is not prorated. Requests to review a member’s 2005 encounters for reinsurance will be accepted through May 15, 2006. OHCA shall have 30 days to evaluate the encounter data for a member identified by the Contractor as having reached the reinsurance threshold. Payments will be made monthly depending on the value of successful encounter claims submitted. Once the OHCA has verified that the member has reached the threshold, the provider will be reimbursed at ninety (90) percent of the fee-for-service value for all of the enrolled member’s submitted capitated services with values exceeding the $1,800.00 threshold for the remainder of the contract year.

5.10 Payment Adjustments

The OHCA will adjust capitation payments based on the member’s enrollment or disenrollment effective dates. The capitation payment will be considered payment in full for all primary care and case management services in Attachment A, which has been incorporated by reference, pursuant to Article 5.1.

ARTICLE 6: OBLIGATIONS OF THE OHCA

6.1 Administrative Responsibilities The OHCA shall:

A. Reimburse the Contractor for non-capitated, Medicaid-compensable, medically necessary services rendered to SoonerCare members in his/her panel in accordance with current Medicaid payment policies and procedures.

B. Provide the Contractor with a monthly list of members who are assigned to the Contractor. The capitation roster will be mailed to the “pay to address” listed in Attachment B.

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SoonerCare 25 Physician Assistant Contract 2005 Revised October 2004

C. Coordinate programs and provide materials to educate SoonerCare members on the appropriate use of health care services.

D. Ensure the member receives accurate oral and written information he or she

needs to make an informed decision about the enrollment process. Such materials shall not contain any statement that the member must enroll in SoonerCare in order to obtain Medicaid benefits or in order not to lose Medicaid benefits.

E. Provide all enrollment notices, informational and instructional materials

relating to members and potential members in a manner and format easily understood. Enrollment materials cannot state that any Contractor is endorsed by CMS, or the Federal or State government.

F. Provide support services to the Contractor in the areas of referral

arrangements, overall utilization management, SoonerCare claims submissions, administrative case management, member education and discrimination policies.

G. Make written information available in the prevalent non-English languages in

the SoonerCare program.

H. Make oral interpretation services available free of charge to each potential member and member. This applies to all non-English languages, not just those that the OHCA identifies as prevalent.

I. Notify members that oral interpretation is available for any language and

written information is available in prevalent languages and how to access those services.

J. Notify members on how to access oral interpretation services.

K. Provide written material in easily understood language and format.

L. Make written material available in alternative formats and in an appropriate

manner that takes into consideration the special needs of those who, for example, are visually limited or have limited reading proficiency.

M. Inform members that information is available in alternative formats and how

to access those formats.

N. Furnish members the grievance, appeal and fair hearing procedures and timeframes within a reasonable time after the member's enrollment and provide written notice to a member of any change in the process.

O. Give each member written notice of any significant change in the

SoonerCare program at least 30 days before the intended effective date of the change.

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SoonerCare 26 Physician Assistant Contract 2005 Revised October 2004

P. Make a good faith effort to give written notice of termination of a Contractor, within 15 days after receipt or issuance of the termination notice, to each member enrolled with the terminated contractor.

Q. Not discriminate for the participation, reimbursement, or indemnification of

any provider who is acting within the scope of his or her license or certification under applicable Sate law, solely on the basis of that license or certification. The OHCA shall not, in provider selection policies and procedures, discriminate against particular providers that serve high-risk populations or specialize in conditions that require costly treatment.

R. Upon declining to contract with individual or groups of providers, must give

the affected providers written notice of the reason for its decision. This provision may not be construed to:

1. require the OHCA to contract with providers beyond the number

necessary to meet the needs of its members 2. preclude the OHCA from using different amounts for different

specialties or for different practitioners in the same specialty; or 3. preclude the OHCA from establishing measures that are designed

to maintain quality of services and control costs and is consistent with its responsibilities to members.

S. Establish mechanisms to ensure that Contractors comply with the timely

access requirements in Section 2.3, monitor regularly to determine compliance and take corrective action if there is a failure to comply.

T. Ensure that the services defined in Attachment A of this contract are in the

amount, duration and scope that is no less than the amount, duration and scope for the same services furnished to beneficiaries under fee-for-service Medicaid.

U. If the OHCA elects to no longer cover a service, it must furnish information

about the services it does not cover to the Contractor. In the event the change in policy occurs during the term of the contract, the OHCA must notify the Contractor within 30 days of the policy change. The OHCA must provide this information to potential members before and during enrollment. The OHCA must also notify members within 90 days after adopting a change in policy with respect to any particular services.

6.2 Conflict of Interest

No official or employee of the State of Oklahoma or the Federal government who exercises any functions or responsibilities in the review or approval of the undertaking or carrying out of the contract shall, prior to the completion of the project, voluntarily acquire any personal interest, direct or indirect, in the contract. All State employees shall be subject to the State law provisions governing conflicts of interest. Contractor shall represent and covenant that it presently has no interest and shall not acquire any interest, direct or indirect, which would conflict in any manner or

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SoonerCare 27 Physician Assistant Contract 2005 Revised October 2004

degree with the performance of its services hereunder. Contractor shall further covenant that, in the performance of the contract, no person having any such known interests shall be employed.

6.3 Nurse Advice Line The OHCA shall provide a Nurse Advice Line (NAL), which will be available to SoonerCare members. The service will be available twenty-four (24) hours per day, seven (7) days per week via a toll free telephone number. The Contractor may include the NAL telephone number on their after-hours message. The Contractor will receive written information about his/her members when the NAL triages to the Emergency Room. This service does not replace the twenty-four (24) hour access provided by the Contractor, nor will the Nurse Advice Line be available to the Contractor for authorization of services. The Nurse Advice Line is available solely to SoonerCare members and the Contractor shall not advise any Medicaid recipient except SoonerCare members to access the Nurse Advice Line.

6.4 Access to a Women’s Health Specialist

The OHCA shall provide all female enrollees with direct access to a women’s health specialist within the Medicaid provider network for covered care necessary to provide women’s routine and preventive health care services. This is in addition to the member’s designated source of primary care if that source is not a women’s health specialist.

ARTICLE 7: MEMBER RIGHTS 7.1 Member Rights and Protection

The Contractor shall comply with any applicable Federal and State laws that pertain to member rights and ensure that its staff and affiliated providers take those rights into account when furnishing services to members. The Contractor is required to guarantee the following rights to SoonerCare panel members. The member has the right to: A. Be treated with respect and with due consideration for his or her dignity and privacy. B. Exercise his or her rights, and that the exercise of those rights does not adversely affect the way the Contractor and the OHCA treat the members. C. Receive information on available treatment options and alternatives, presented in a manner appropriate to member's condition and ability to understand. D. Participate in decisions regarding his or her health care, including the right to refuse treatment. E. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.

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SoonerCare 28 Physician Assistant Contract 2005 Revised October 2004

F. Request and receive a copy of his or her medical records and to request that they be amended or corrected, as specified in 45 CFR Part 164.

ARTICLE 8: GENERAL TERMS AND CONDITIONS 8.1 Contract Period and Renewal

A. This contract shall be effective upon Contractor signing, and receipt, processing and acceptance by OHCA and ending December 31, 2005.

B. Contract Year 2005 SoonerCare contract contains two optional one-year renewal periods that may renew the terms of this agreement through December 31, 2007. C. All terms and conditions stated herein are subject to approval from the Centers for Medicare and Medicaid Services (CMS). D. Options to renew shall be effected by written notice from the OHCA no later than October 1 of each year. Actuarially certified rates will be developed for each contract year in accordance with generally accepted actuarial principles and practices. The rates shall be appropriate for the population to be covered and the services to be furnished under the benefit package.

8.2 Termination

A. This contract may be terminated by either party, upon mutual agreement or by proper notice as described below. The OHCA shall reassign recipients assigned to the Contractor to another PCP/CM should this contract be terminated.

B. With respect to termination by mutual agreement or unilateral termination,

effective notice shall be given by providing written notice to the address contained in Article 8.9 below, at least thirty (30) calendar days prior to termination. The effective date of termination shall be the last day of the month at least thirty (30) days from the date the OHCA receives the proper notification of termination.

C. With respect to termination by either party for breach of the contractual

obligations, thirty (30) days notice shall be provided in accordance with Article 8.9 below. The notice shall be effective the last day of the month after thirty (30) days have elapsed since the date of the notice. The notice shall state the reason(s) for termination and may state a reasonable period, not less than thirty (30) days, in which the alleged breach (es) may be cured.

D. In the event of fraud, Medicaid program abuse or jeopardy to the health and

safety of any recipient, the OHCA may terminate this contract immediately without further notice.

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SoonerCare 29 Physician Assistant Contract 2005 Revised October 2004

E. In the event funding from State, Federal, or other sources is withdrawn, reduced, or limited in any way after the effective date of the contract and prior to the anticipated contract expiration date, the State may terminate the contract upon written notice thirty (30) calendar days prior to the effective date of termination. If the effective date of funding withdrawal, reduction, or limitation does not allow for a full thirty (30) day notice, a shorter notice period shall be effective.

F. If the State chooses to convert any or all of the areas in the SoonerCare

program to fully capitated Managed Care Organization coverage or any other alternative model rather than the Primary Care Case Management system, this contract may be terminated as of the date of such conversion. Notice of such termination, if applicable, shall be sent to the Contractor no less than thirty (30) days prior to conversion.

G. In the event the contract is terminated and monies are owed from the

Contractor to the OHCA, the OHCA may recoup monies owed a Contractor under his/her fee-for-service contract.

H. Notice of termination shall be sent by certified U.S. mail, return receipt

requested.

I. In the event the OHCA implements a different managed care model, the State shall notify the Contractor of the changes in the program and advise the Contractor of the status of the contract. The State shall notify the Contractor of the change of status of the members residing in the affected areas and the changes in their health care delivery system.

8.3 Compliance with All Applicable Laws and Regulations Each party to this contract shall be bound by all applicable Federal law, Federal regulations, State law and promulgated state regulations. Changes to State or Federal law that affect the status of the program shall be cause for termination.

8.4 Compliance with Specific Laws and Regulations

A. The Contractor must agree to comply with all State and Federal laws,

regulations, and policies as they exist or as amended. The Contractor agrees to comply with these Federal laws to the extent that they are applicable:

1. the Age Discrimination in Employment Act, 29 U.S.C. § 621 et

seq.; 2. the Rehabilitation Act, 29 U.S.C. § 701 et seq.; 3. the Drug-Free Workplace Act, 41 U.S.C. § 701 et seq.; 4. Title XIX of the Social Security Act (Medicaid), 42 U.S.C. § 1396

et seq.; 5. Title VI of the Civil Rights Act; 6. the Age Discrimination Act, 42 U.S.C. § 6101 et seq.; 7. the Americans with Disabilities Act, 42 U.S.C. § 12101 et. seq.; 8. the Oklahoma Worker’s Compensation Act. 85 O.S. § 1 et. seq.;

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SoonerCare 30 Physician Assistant Contract 2005 Revised October 2004

9. the Fair Labor Standards Act, 29 U.S.C. § 201 et. seq.; 10. the Equal Pay Act, Public Law 88-38 11. the Vietnam Era Veterans Re-adjustment Act of 1974, Public Law

93-509 12. 31 U.S.C. § 1352 and 45 C.F.R. § 93.100 et seq., which (1)

prohibit use of federal funds paid under this Agreement to lobby Congress or any federal official to enhance or protect the monies paid under this Agreement and (2) require disclosures to be made if other monies are used for such lobbying;

13. 5 U.S.C. § 1352 and 45 C.F.R. § 741.1 et seq. and Presidential Executive Orders11141, 11246 and 11375, which together require certain federal Contractors and sub-contractors to institute affirmative action plans to ensure absence of discrimination for employment because of race, color, religion, sex, or national origin;

14. 45 C.F.R. Part 76, §§76.105 and 76.110, Debarment, Suspension and other Responsibility Matters; and

15. 74 O.S. §§ 85.44(B)(C) and 45 C.F.R. §74.34 with regard to equipment (as defined by U.S. Office of Management and Budget Circular A-87) purchased with monies received from OHCA pursuant to this contract.

16. Title IX of the Education Amendments of 1972. 17. Section 1903(m) of the Social Security Act-Managed Care

Organizations. 18. Section 1932(b)(3)(D) of the Social Security Act – Anti-gag

Clause. The Contractor shall not prohibit, or otherwise restrict a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his or her patient:

a. for the enrollee’s health status, medical care, or treatment options, including any alternative treatment that may be self-administered.

b. for any information the enrollee needs in order to decide among all relevant treatment options.

c. for the risks, benefits, and consequences of treatment or non-treatment.

d. for the enrollee’s right to participate in decisions regarding his or her health care, including the right to refuse treatment, and to express preferences about future treatment decisions.

18. 42 USC 7401 et seq., Clean Air Act, and the Federal Water

Pollution Control Act, as amended at 33 USC 1251 et seq. Contractor shall report violations to the applicable grantor Federal agency and the US EPA Assistant Administrator for Enforcement.

19. State energy conservation plan issued in compliance with the Energy Policy and Conservation Act (Public Law 94-165).

B. The explicit inclusion of some statutory and regulatory duties in this contract

shall not exclude other statutory or regulatory duties.

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SoonerCare 31 Physician Assistant Contract 2005 Revised October 2004

C. All questions pertaining to validity, interpretation, and administration of this contract shall be determined in accordance with the laws of the State of Oklahoma, regardless of where any service is performed.

D. If any portion of this contract is found to be in violation of State or Federal

Statutes, that portion shall be stricken from this contract and the remainder of the contract shall remain in full force and effect.

E. The Contractor agrees to ensure that its sub-contractors will comply with

these laws as applicable. In the event that the Contractor may, from time to time, request the OHCA to make policy determinations or to issue operating guidelines required for proper performance of the contract, the OHCA shall do so in a timely manner, and the Contractor shall be entitled to rely upon and act in accordance with such policy determinations and operating guidelines and shall incur no liability in doing so unless the Contractor acts negligently, maliciously, fraudulently, or in bad faith. The OHCA’s Business and Contracts Manager may only make such determinations.

8.5 Grievance and Appeal Procedures

A. In the event of a member grievance, the Contractor shall attempt to resolve

the complaint informally and instruct the member to contact the OHCA’s Legal Division if the member wishes to file a written grievance.

B. In the event of a formal appeal, the Contractor shall be available to the OHCA

and shall cooperate with the OHCA as needed to assist in the resolution of such grievance or appeal of an adverse action.

C. The Contractor shall conform and adhere to all the OHCA procedures regarding

grievances and appeals.

8.6 Waivers

A. No covenant, condition, duty, obligation, or undertaking contained in or made a part of the contract shall be waived except by the written contract of the parties. Forbearance or indulgence in any form or manner by either party in any regard whatsoever shall not constitute a waiver of the covenant, condition, duty, obligation, or undertaking to be kept, performed, or discharged by the party to which the same may apply. Notwithstanding any such forbearance or indulgence, the other party shall have the right to invoke any remedy available under law or equity until complete performance or satisfaction of all such covenants, conditions, duties, obligations, and undertakings.

B. Waiver of any breach of any term or condition in the contract shall not be

deemed a waiver of any prior or subsequent breach. No term or condition of the contract shall be held to be waived, modified, or deleted except by an instrument, in writing, signed by the parties hereto.

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SoonerCare 32 Physician Assistant Contract 2005 Revised October 2004

8.7 Assignment of the Contract

Contractor shall not sell, transfer, assign, or otherwise dispose of the contract or any portion thereof or of any right, title, or interest therein without the prior written consent of the OHCA. Such consent, if granted, shall not relieve Contractor of its responsibilities under the contract. This provision includes reassignment of the contract due to change in ownership.

8.8 Hold Harmless

The Contractor shall hold harmless and indemnify the State, and any of its officers, agents and employees from: A. Any claims for damages or losses to any person or firm injured or

damaged by erroneous or negligent acts, including disregard of State or Federal Medicaid regulations or statutes, by the Contractor, his/her partners, coworkers, employees, or sub-contractors in the performance of the contract.

B. Any claims for damages or losses resulting to any person or firm injured or

damaged by the Contractor, his/her partners, coworkers, employees, or sub-contractors by the publication, translation, reproduction, delivery, performance, use, or disposition of any data processed under this contract in a manner not authorized by this contract or by Federal or State regulations or statutes.

C. Any failure of the Contractor, his/her partners, coworkers, employees, or sub-

contractors to observe the Federal or State laws, including, but not limited to, labor laws and minimum wage laws.

D. Any claims for damages, losses, attorney fees, or costs associated with legal

expenses, including, but not limited to, those incurred by or on behalf of the State in connection with the defense of claims for such injuries, losses, claims, or damages specified above.

8.9 Notices

Any notices sent to the OHCA in accordance with this contract shall be sent to: SoonerCare Program Attn: Contractor Services Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105 Any notice to the Contractor shall be mailed to the address listed on the primary office location page.

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SoonerCare 33 Physician Assistant Contract 2005 Revised October 2004

8.10 Severance If any provision of this contract is determined to be invalid for any reason, such invalidity shall not affect any other provision, and the invalid provision shall be wholly disregarded.

8.11 Modifications The written representations made in this memorialization of the contract constitute the sole basis of the parties’ contractual relationship. No oral representation by either party relating to the services covered by this contract shall be binding on either party. This contract can only be modified by mutual agreement made in writing and signed by both parties. Should the Contractor not sign a contract modification issued by the OHCA, then the entire contract may be voided.

8.12 Incorporation by Reference

Attachments A to J, attached to this contract, are incorporated into this contract by reference and made part of the contract.

8.13 Choice of Law All questions pertaining to validity, interpretation, and administration of this contract shall be determined in accordance with the laws of the State of Oklahoma, regardless of where any service is performed.

8.14 Venue The venue for civil actions arising from this contract shall be Oklahoma County, Oklahoma. For the purpose of Federal jurisdiction, in any action in which the State of Oklahoma is a party, venue shall be the United States District Court for the Western District of Oklahoma.

8.15 Miscellaneous Reimbursement Requirements

Violation of this paragraph at the contract’s execution or during any part of the term of the contract shall immediately render the contract void. (Check any applicable) (1) ______ As a condition of the Contractor’s employment as a physician, he/she is required to turn over fees for services provided pursuant to this contract to his/her employer. (2) ______ As a matter of contractual arrangement with the facility where the Contractor performs services pursuant to this contract, the facility submits bills for the Contractor’s services. If either (1) or (2) of this paragraph is checked, Contractor directs the OHCA to make payment to Contractor’s employer or billing facility and will provide that employer’s or facility’s direct deposit information for that purpose. Contractor shall be responsible for the accuracy of that information and for updating it as needed.

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SoonerCare 34 Physician Assistant Contract 2005 Revised October 2004

8.16 Attestation

By signing this contract, the Contractor signifies that information included herein is true and accurate to the best of his or her knowledge. EXECUTED BY: _________________________________ ____________ Contractor’s Signature Date _________________________________ Contractor’s Printed Name

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SoonerCare 35 Physician Assistant Contract 2005 Revised October 2004

AFFIDAVIT [Required by 74 Okla. Stat. §§85.23 and 85.42(B)] STATE OF OKLAHOMA ) ) SS. COUNTY OF _______________)

________________________, of lawful age, being first duly sworn on oath, says: (Contractor’s Printed Name)

1. (S)he is the duly authorized agent of _______________________________, (Contractor’s Printed Name)

the Contractor under the contract which is attached to this statement, for the purpose of certifying the facts pertaining to the giving of things of value to government personnel in order to procure said contract; 2. (S)he is fully aware of the facts and circumstances surrounding the making of the contract to which this statement is attached and has been personally and directly involved in the proceedings leading to the procurement of said contract; 3. Neither the Contractor nor anyone subject to the Contractor’s direction or control has paid, given, or donated or agreed to pay, give, or donate to any officer or employee of the State of Oklahoma any money or other thing of value either directly or indirectly, in procuring the contract to which this statement is attached; and 4. No person who has been involved in any manner in the development of the contract to which this statement is attached while employed by the State of Oklahoma shall be employed to fulfill any of the services provided for under said contract. This paragraph shall not preclude faculty and staff of institutions within the State System of Higher Education from negotiating and participating in research grants and educational contracts. This paragraph shall not apply to an agreement between the Oklahoma Health Care Authority and another agency of the State of Oklahoma. ________________________________________ (Contractor’s Signature and Title) Subscribed and sworn to before me this _______ day of __________, 20______. (SEAL) ___________________________________ Notary Public (or Clerk or Judge)

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Attachment A

SoonerCare Revised August 2005

ATTACHMENT A

Medicaid covered services not listed in the capitated benefit section will be reimbursed at the current Medicaid fee-for-service rate subject to all current benefit limitations and prior authorization guidelines.

PCP/CM

Primary Care Capitated Services

OFFICE VISIT - NEW PATIENT

CPT Code

Description

99201 Office and other outpatient medical service, new patient; brief service 99202 Office and other outpatient medical service, new patient; limited service 99203 Office and other outpatient medical service, new patient; intermediate service 99204 Office and other outpatient medical service, new patient; extended service 99205 Office and other outpatient medical service, new patient; comprehensive service

OFFICE VISIT - ESTABLISHED PATIENT

CPT Code

Description

99211 Office and other outpatient medical service, established patient; minimal service 99212 Office and other outpatient medical service, established patient; brief service 99213 Office and other outpatient medical service, established patient; limited service 99214 Office and other outpatient medical service, established patient; intermediate service 99215 Office and other outpatient medical service, established patient; extended service

NEW PATIENT - PREVENTIVE MEDICINE

CPT Code

Description

99381 Office and other outpatient medical service, initial preventive medicine evaluation and management, infant 99382 early childhood, age 1-4 99383 late childhood, age 5-11 99384 adolescent, age 12-17 99385 18-39 years 99386 40-64 years 99387 65 years and over

ESTABLISHED PATIENT - PREVENTIVE MEDICINE

CPT Code

Description

99391 Periodic preventive medicine re-evaluation and management of an individual, infant 99392 early childhood, age 1-4 99393 late childhood, age 5-11 99394 adolescent, age 12-17 99395 18-39 years 99396 40-64 years 99397 65 years and over

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Attachment A Page 2

SoonerCare Revised August 2005

THERAPEUTIC OR DIAGNOSTIC INJECTIONS

CPT Code Description

90782 Therapeutic or diagnostic injection (specify material injected); subcutaneous or intramuscular 90788 Intramuscular injection of antibiotic (specify)

IMMUNIZATIONS/INJECTIONS

CPT Code Description 90465 Immunization administration fee under 8 years of age (percutaneous, intradermal, subcutaneous or IM) injections 90466 Immunization administration fee under 8 years of age (percutaneous, intradermal, subcutaneous or IM) injections 90467 Immunization administration fee under 8 years of age (intranasal or oral routes of administration) 90468 Immunization administration fee under 8 years of age (intranasal or oral routes of administration) 90471 Immunization administration fee (this code is used if vaccine is obtained through the Vaccines for Children Program) 90472 Immunization administration fee (this code is used if vaccine is obtained through the Vaccines for Children Program) 90473 Immunization administration by intranasal or oral route 90474 Immunization administration by intranasal or oral route 90632 Hepatitis A vaccine, adult dosage, for intramuscular use 90633 Hepatitis A vaccine, pediatric/adolescent dosage – 2 dose schedule, for intramuscular use 90634 Hepatitis A vaccine, pediatric/adolescent dosage – 3 dose schedule, for intramuscular use 90645 Hemophilus influenza b vaccine (Hib) HbOC conjugate (4 dose schedule), for intramuscular use 90646 Hemophilus influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use 90647 Hemophilus influenza b vaccine (Hib), PRP conjugate (3 dose schedule), for intramuscular use 90648 Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use 90657 Influenza virus vaccine, split virus, 6-35 months dosage, for intramuscular or jet injection use 90658 Influenza virus vaccine, split virus, 3 years and above dosage, for intramuscular or jet injection use 90660 Influenza virus vaccine, live, for intranasal use 90669 Pneumoccoccal conjugate vaccine, polyvalent, for intramuscular use 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), for intramuscular use 90701 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use 90702 Diphtheria and tetanus toxoids (DT) absorbed for pediatric use, for intramuscular use 90703 Tetanus toxoid absorbed, for intramuscular or jet injection use 90704 Mumps virus vaccine, live, for subcutaneous or jet injection use 90705 Measles virus vaccine, live, for subcutaneous or jet injection use 90706 Rubella virus vaccine, live, for subcutaneous or jet injection use 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous or jet injection use 90708 Measles and rubella virus vaccine, live, for subcutaneous or jet injection use 90710 Measles, mumps, rubella and varicella vaccine (MMRV), live for subcutaneous use 90712 Poliovirus vaccine, (any types) (OPV), live, for oral use 90713 Poliovirus vaccine, inactivated, (IPV), for subcutaneous use 90716 Varicella virus, vaccine, live, for subcutaneous use 90718 Tetanus and diphtheria toxoids absorbed for adult use (Td), for intramuscular or jet injection 90719 Diphtheria toxoid, for intramuscular use 90720 Diphtheria, tetanus and pertussis (DTP) and Hemophilus influenza B (HIB) vaccine 90721 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DtaP-Hib), for

intramuscular use 90723 Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and polio virus vaccine, inactivated (DtaP-HepB-IPV), for

intramuscular use 90732 Pneumococcal polysaccharide vaccine, 23-valent, adult dosage, for subcutaneous or intramuscular use 90371 Hepatitis B immune globulin (HBlg), human, for intramuscular use 90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use 90744 Hepatitis B vaccine, pediatric or pediatric/adolescent dosage, for intramuscular use 90746 Hepatitis B vaccine, adult dosage, for intramuscular use 90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage, for intramuscular use 90748 Hepatitis B and Hemophilus influeneza b vaccine (HepB-Hib), for intramuscular use

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Attachment A Page 3

SoonerCare Revised August 2005

The Provider must provide adults with the tetanua, pneumococcal, hepatitis A, hepatitis B and influenza vaccine when medically necessary.

IMMUNOLOGY

CPT Code

Description

86308 Heterophile antibodies; screening URINALYSIS

CPT Code

Description

81002 Without microscopy, non-automated 81025 Urine pregnancy test

CHEMISTRY

CPT Code

Description

82465 Cholesterol, serum or whole blood, total 82270 Blood, occult, feces screening, 1-3 simultaneous determinations 82947 Glucose, quantitative 83718 Lipoprotein, direct measurement, HDL cholesterol

HEMATOLOGY AND COAGULATION

CPT Code

Description

85013 Spun microhematocrit 85014 Other than spun hematocrit

PATHOLOGY

CPT Code

Description

87804 Infectious agent antigen detection by immunoassay with direct optical observation; Influenza 87880 Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group A

Alternative codes used to bill for the services listed above may be changed to codes listed in the benefit package. Additional payment will not be generated.

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SoonerCare 2005

ATTACHMENT B

SoonerCare Provider Program Information

PLEASE READ THE DIRECTIONS CAREFULLY

• All providers must complete the Uniform Credentialing Application. It must be 100% complete,

including required documents.

• The following documents are required for your application to be considered complete: current

contractor’s state(s) license(s), face sheet of current professional liability (malpractice) insurance

policy, board certification documentation (if applicable), license(s) for each Nurse Midwife,

Nurse Practitioner or Physician Assistant working as an extender.

• To apply for a Fee-For-Service Medicaid contract, please contact Provider Enrollment at

1-800-522-0114 or 405-522-6205.

• Documentation of prescriptive authority must be included.

• If you have questions regarding the SoonerCare Program, please feel free to contact a Provider

Representative at 1-877-823-4529.

SoonerCare Provider Information

Do you currently provide OB care for SoonerCare members? □Yes □ No

______________________________________________________________________________________________________________

Please check ONE of the following for age/gender of SoonerCare members you wish to treat:

Male/Female/Any Age □ Male/Female/Age 0 – 14 □ Females/Age 14 – over □

Male/Female/14 – over □

___________________________________________________________________________________________________

Please specify the desired total patient capacity the provider is able and willing to enroll: __________

(refer to Article 3.1C for program capacity information.)

Specify the total number of office hours the provider is available to provide care to SoonerCare enrollees:

(Program capacity will be prorated based on availability.)

□ 40 office hours per week □ specify office hours available per week ____

___________________________________________________________________________________________________

Are you currently a participant in the Vaccines for Children (VFC) program? □ Yes □ No

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SECTION 1: PERSONAL INFORMATION

Name Last First Middle Suffix Professional Degree Gender: Male Female Other Name By Which You Have Been Known Dates This Name Was Used: From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Other Name By Which You Have Been Known Dates This Name Was Used: From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Social Security Number ___ ___ ___ - ___ ___ - ___ ___ ___ ___ NPID (formerly UPIN) Date of Birth: ___ ___ - ___ ___ - ___ ___ ___ ___ Place of Birth Citizenship Visa Type Visa Number (provide copy) Expiration Date Your Personal Medicare Number Your Personal Medicaid Number

SECTION 2: DIRECTORY INFORMATION Mailing Address For All Credentialing Correspondence: Street Address Suite Number City State Zip Code ( ) ( ) ( ) Phone Number Fax Number Emergency or Pager Number ( ) Answering Service Number E-Mail Address Contact Person For Credentialing Correspondence: This Section continues on next page.

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-Section 2 Continued- Office Street Address: Street Address Suite Number City State Zip Code ( ) ( ) ( ) Phone Number Fax Number Emergency or Pager Number ( ) Answering Service Number E-Mail Address Office Mailing Address: Street Address Suite Number City State Zip Code ( ) ( ) ( ) Phone Number Fax Number Emergency or Pager Number ( ) Answering Service Number E-Mail Address Office Billing Address (If Different From Claims Payment Address): Street Address Suite Number City State Zip Code ( ) ( ) ( ) Phone Number Fax Number Emergency or Pager Number ( ) Answering Service Number E-Mail Address Claims Payment Address (If Different From Office Billing Address): Street Address Suite Number City State Zip Code ( ) ( ) ( ) Phone Number Fax Number Emergency or Pager Number ( ) Answering Service Number E-Mail Address Make Checks Payable To:

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SECTION 3: CURRENT PROFESSIONAL PRACTICE Primary Specialty (or field of practice) Subspecialty % Of Time Secondary Specialty Subspecialty % Of Time Do you wish to be listed as: ___ Primary Care Provider ___ Specialist ___ Hospitalist ___ On-Call ___ Other (specify) If you are a primary care physician, list special diagnostic or treatment procedures performed in your office(s): ___ Yes ___ No Are you accepting new patients?

___ Yes ___ No Are you willing, in the future to accept new patients?

___ Yes ___ No Do you admit your own patients to hospitals?

If no, please explain how your patients will be admitted, which hospital and who will provide patient care.

___ Yes ___ No Are you willing to accept current patients if they convert to the healthcare plan to which you are applying?

___ Yes ___ No Are you a member of an Independent Practice Association or a Physician Hospital Association? If yes,

complete the following:

Name: Street Address Suite Number City State Zip Code ( ) ( ) ( ) Phone Number Fax Number Answering Service Number Name: Street Address Suite Number City State Zip Code ( ) ( ) ( ) Phone Number Fax Number Answering Service Number List any restrictions on your practice (i.e. patient age and gender):

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SECTION 4: EDUCATION Medical/Dental/Graduate Professional Schools List all, completed or not. Continue in Section 14 if needed. (1) Institution Degree Awarded Mailing Address City State Zip Code Telephone Number: ( )

Dates Attended (mo/day/year) From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Graduation Date ___ ___ - ___ ___ - ___ ___ ___ ___

(2) Institution Degree Awarded Mailing Address City State Zip Code Telephone Number: ( )

Dates Attended (mo/day/year) From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Graduation Date ___ ___ - ___ ___ - ___ ___ ___ ___

(3) Institution Degree Awarded Mailing Address City State Zip Code Telephone Number: ( )

Dates Attended (mo/day/year) From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Graduation Date ___ ___ - ___ ___ - ___ ___ ___ ___

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SECTION 5: TRAINING Internship/Residency/Fellowship/Preceptorship/Other

List all, completed or not. If you require additional space, continue in Section 14, or attach a separate sheet. (1) Type of Program:

___ Internship ___ Residency ___ Fellowship ___ Preceptorship ___ Other (specify) Was program successfully completed: ___ Yes ___ No

Specialty Institution Your Program Director

( ) Address City State Zip Code Phone Number Dates Attended (mo/day/year) From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ (2) Type of Program:

___ Internship ___ Residency ___ Fellowship ___ Preceptorship ___ Other (specify) Was program successfully completed? ___ Yes ___ No

Specialty Institution Your Program Director ( ) Address City State Zip Code Phone Number Dates Attended (mo/day/year) From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ (3) Type of Program:

___ Internship ___ Residency ___ Fellowship ___ Preceptorship ___ Other (specify) Was program successfully completed? ___ Yes ___ No

Specialty Institution Your Program Director ( ) Address City State Zip Code Phone Number Dates Attended (mo/day/year) From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ (4) Type of Program:

___ Internship ___ Residency ___ Fellowship ___ Preceptorship ___ Other (specify) Was program successfully completed? ___ Yes ___ No

Specialty Institution Your Program Director ( ) Address City State Zip Code Phone Number Dates Attended (mo/day/year) From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___

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SECTION 6: ACADEMIC APPOINTMENTS List all, past and present. If additional space is needed, copy this sheet or continue in Section 14. (1) ( ) Institution and Address City State Zip Code Phone Number

From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Position/Rank Inclusive Dates (mo/day/year) (2) ( ) Institution and Address City State Zip Code Phone Number From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Position/Rank Inclusive Dates (mo/day/year) (3) ( ) Institution and Address City State Zip Code Phone Number From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Position/Rank Inclusive Dates (mo/day/year)

SECTION 7: HEALTH CARE AFFILIATIONS List, in chronological order, all hospital/health system affiliations where you have ever been employed, practiced, associated, or privileged for the purpose of providing patient care. Do not list affiliations that were part of your training (Section 5). If additional space is required, copy this sheet or continue in Section 14. Indicate which of these is your “current primary and secondary admitting facility” (where you currently spend the greatest portion of your time). (1) ___ Primary ___ Secondary Facility Name ( ) Complete Mailing Address City State Zip Code Telephone Number From:___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ ___ Dates of Appointment (mo/day/year) Staff Category Reason for Discontinuance Department or Service (2) ___ Primary ___ Secondary Facility Name ( ) Complete Mailing Address City State Zip Code Telephone Number From:___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Dates of Appointment (mo/day/year) Staff Category Reason for Discontinuance Department or Service This section continues on next page.

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-Section 7 Continued- (3) ___ Primary ___ Secondary Facility Name ( ) Complete Mailing Address City State Zip Code Telephone Number From:___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ ___ Dates of Appointment (mo/day/year) Staff Category Reason for Discontinuance Department or Service

SECTION 8: OTHER PROFESSIONAL WORK HISTORY List, chronologically, all professional work history (i.e. clinics, partnerships, solo/group practices, employment). Include secondary agencies or clinics such as public health and family planning where you perform duties. Account for all time gaps of thirty (30) days or more. If additional space is needed, copy this page or continue in Section 14. (1) Name and Nature of Affiliation ( ) Mailing Address City State Zip Code Telephone Number From:___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Dates of Affiliation (mo/day/year) Reason for Discontinuance (2) Name and Nature of Affiliation ( ) Mailing Address City State Zip Code Telephone Number From:___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Dates of Affiliation (mo/day/year) Reason for Discontinuance (3) Name and Nature of Affiliation ( ) Mailing Address City State Zip Code Telephone Number From:___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Dates of Affiliation (mo/day/year) Reason for Discontinuance US Military/Public Health Service List all medical and surgical locations and dates. From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Location Branch of Service From: ___ ___ - ___ ___ - ___ ___ ___ ___ to ___ ___ - ___ ___ - ___ ___ ___ ___ Location Branch of Service

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SECTION 9: PROFESSIONAL LICENSES List all pending, current, and past professional licenses, registrations, and certifications to practice in your field. Include states where you have ever applied to practice. Examples of “type” of license are MD, DO, DDS, PA, DC, CRNA, MSW, etc. Oklahoma ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ State Type Number Original Date of Issue Expiration Date ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ State Type Number Original Date of Issue Expiration Date ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ State Type Number Original Date of Issue Expiration Date ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ State Type Number Original Date of Issue Expiration Date ___ ___ - ___ ___ - ___ ___ ___ ___ USMLE/ECFMG Number Certification Date

SECTION 10: CERTIFICATIONS AND REGISTRATIONS List all other current certifications and registrations. (DEA=Federal Drug Enforcement Administration; BNDD=the Oklahoma CDS; CDS=Controlled Dangerous Substances) DEA ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ State Type Number Original Date of Issue Expiration Date DEA ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ State Type Number Original Date of Issue Expiration Date Oklahoma BNDD ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ State Type Number Original Date of Issue Expiration Date CDS ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ State Type Number Original Date of Issue Expiration Date BOARD CERTIFICATION Are you Board Certified? ___ Yes ___ No Name of Board ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Date Initially Certified Date Most Recently Recertified Date Certification Expires ___ Yes ___ No Have you ever been examined by any specialty board but failed to pass? If yes, provide details. This section continues on next page.

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-Section 10 Continued- SUBSPECIALTY CERTIFICATION AND ADDED QUALIFICATIONS Subspecialty or Added Qualification Name of Board ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Date Initially Certified Date Most Recently Recertified Date Certification Expires Subspecialty or Added Qualification Name of Board ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Date Initially Certified Date Most Recently Recertified Date Certification Expires BOARD QUALIFICATIONS ___ Yes ___ No If you are not certified, are you qualified to sit for the exam in a primary or subspecialty board or added qualification?

___ Yes ___ No Are you planning to take the exam?

___ Yes ___ No Are you scheduled to take the exam? If yes, attach confirmation letter.

Date Scheduled: Oral ___ ___ - ___ ___ - ___ ___ ___ ___

Written ___ ___ - ___ ___ - ___ ___ ___ ___

Other ___ ___ - ___ ___ - ___ ___ ___ ___ Subspecialty or Added Qualification Name of Board Date Qualified ___ ___ - ___ ___ - ___ ___ ___ ___ Date Qualification Expires ___ ___ - ___ ___ - ___ ___ ___ ___ Classifications: ___ Yes ___ No Are you certified in CPR? Expires ___ ___ - ___ ___ - ___ ___ ___ ___

___ Yes ___ No Basic Life Support (BLS) Expires ___ ___ - ___ ___ - ___ ___ ___ ___ ___ Yes ___ No Advanced Cardiac Life Support (ACLS) Expires ___ ___ - ___ ___ - ___ ___ ___ ___ ___ Yes ___ No Health Care Provider (CoreC) Expires ___ ___ - ___ ___ - ___ ___ ___ ___ ___ Yes ___ No Advanced Trauma Life Support (ATLS) Expires ___ ___ - ___ ___ - ___ ___ ___ ___ ___ Yes ___ No Neonatal Advanced Life Support (NALS) Expires ___ ___ - ___ ___ - ___ ___ ___ ___ ___ Yes ___ No Pediatric Advanced Life Support (PALS) Expires ___ ___ - ___ ___ - ___ ___ ___ ___ ___ Yes ___ No Other Expires ___ ___ - ___ ___ - ___ ___ ___ ___

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SECTION 11: OFFICE INFORMATION Primary Office

Group Name Name As It Appears On Your W-9 (if applicable) Business Owned By Type of Practice: ___ Solo ___ Partnership ___ Single-Specialty Group ___ Multi-Specialty Group Other (specify) Office Manager Nurse Coordinator Group Medicare Number Group Medicaid Number IRS Tax ID Number Does this office have lab service? ___ Yes ___ No Reference Lab? ___ Yes ___ No On Site? ___ Yes ___ No CLIA ID # CLIA Waiver # Does your office have the following: ___ Yes ___ No Radiology List all independent licensed non-physicians working in this office.

___ Yes ___ No EKG

___ Yes ___ No Audiology Name Provider Type License Number

___ Yes ___ No Treadmill

___ Yes ___ No Sigmoidoscopy

___ Yes ___ No Wheelchair/handicapped access?

___ Yes ___ No Other services for the disabled? Fluent Languages:

If yes, please list: You

___ Yes ___ No Other: Your Staff

Other Resources

___ Yes ___ No Does this office meet all state and local fire, safety and sanitation requirements?

___ Yes ___ No Do you provide 24-hour, seven day a week coverage?

Office Hours:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday From: To: List name, specialty, and phone number of physicians covering your practice in your absence. Attach an additional sheet if necessary. Note: These practitioners must be affiliated with the organization to which you are applying. Name Specialty Telephone ( ) Name Specialty Telephone ( ) Name Specialty Telephone ( ) Name Specialty Telephone ( ) ___ Yes ___ No Do you or your business own, operate, manage or participate in any medical enterprise or business? If yes, explain on a separate attachment.

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SECTION 11: OFFICE INFORMATION Secondary Office

Group Name Name As It Appears On Your W-9 (if applicable) Business Owned By Type of Practice: Solo Partnership Single-Specialty Group Multi-Specialty Group Other (specify) Office Manager Nurse Coordinator Group Medicare Number Group Medicaid Number IRS Tax ID Number

Does this office have lab service? Yes No Reference Lab? Yes No On Site? Yes No CLIA ID # CLIA Waiver # Does your office have the following: Yes No Radiology List all independent licensed non-physicians working in this office.

Yes No EKG

Yes No Audiology Name Provider Type License Number

Yes No Treadmill

Yes No Sigmoidoscopy

Yes No Wheelchair/handicapped access?

Yes No Other services for the disabled? Fluent Languages:

If yes, please list: You

Yes No Other: Your Staff

Other Resources

Yes No Does this office meet all state and local fire, safety and sanitation requirements?

Yes No Do you provide 24-hour, seven day a week coverage?

Office Hours:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday From: To: List name, specialty, and phone number of physicians covering your practice in your absence. Attach an additional sheet if necessary. Note: These practitioners must be affiliated with the organization to which you are applying. Name Specialty Telephone ( ) Name Specialty Telephone ( ) Name Specialty Telephone ( ) Name Specialty Telephone ( ) Yes No Do you or your business own, operate, manage or participate in any medical enterprise or business? If yes, explain on a separate attachment.

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SECTION 12: COPIES OF REQUIRED DOCUMENTS Please include a copy of the following with this application. Practitioner should check off needed items that are being attached to this application. Attached Item Oklahoma Bureau of Narcotics and Dangerous Drugs Registration (BNDD)

Current Federal DEA Registration Certificate

Emergency Care Training Certificates (CPR, etc., if certified)

Photo Identification

Curriculum Vitae

Tax Identification Information Form W-9

SECTION 13: ATTESTATION All information and documentation contained in this application is true, correct and complete to my best knowledge and belief. I further acknowledge that any material misstatements in or omissions from this application may constitute cause for denial of my application for staff membership, privileges, or participation. Name (printed) Signature Date NOTE: Practitioners are reminded that each organization will require submission of additional information.

SECTION 14: ADDITIONAL INFORMATION This page is furnished for your convenience in completing questions or providing additional information. Please make as many copies of this page as you require to fully answer all questions. As appropriate, note section number and question number that you are addressing.

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SoonerCare Revised August 2005

Attachment C Monthly Rate Schedule

Effective August 1, 2005

through December 31, 2005

TANF Members

Rate Category Age Base Rate Case Management

Total Cap. Payment

Male/Female <1 $30.38 $3.00 $33.38 Male/Female 1 $15.45 $3.00 $18.45 Male/Female 2-5 $15.45 $2.00 $17.45 Male/Female 6-14 $ 9.62 $2.00 $11.62 Female 15-20 $20.87 $2.00 $22.87 Male 15-20 $ 7.06 $2.00 $ 9.06 Female 21-44 $23.72 $2.00 $25.72 Male 21-44 $17.19 $2.00 $19.19 Male/Female 45+ $29.57 $2.00 $31.57

ABD Members

Rate Category Age Base Rate Case

Management Total Cap. Payment

Male/Female <1 $38.65 $3.00 $41.65 Male/Female 1 $28.28 $3.00 $31.28 Male/Female 2-5 $28.28 $3.00 $31.28 Male/Female 6-14 $14.98 $3.00 $17.98 Female 15-20 $18.21 $3.00 $21.21 Male 15-20 $ 9.55 $3.00 $12.55 Female 21-44 $24.68 $3.00 $27.68 Male 21-44 $14.29 $3.00 $17.29 Male/Female 45+ $19.95 $3.00 $22.95 *Please note that these rates will be paid for the capitated services listed in the benefit package. Covered services provided which are not in the capitated benefit package will be paid on the current Medicaid fee-for-service schedule.

Individuals who are dually eligible for Medicare/Medicaid are not part of the program at this time.

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SoonerCare 2005

ATTACHMENT D OKLAHOMA HEALTH CARE AUTHORITY

Electronic Funds Transfer Authorization

1. Name: _______________________________________________________________________________

2. Medicaid Provider Number: _________________________________________________________________ [ ] New Enrollment

[ ] Change Bank, etc.

[ ] Correct Account or Bank Transit Number

[ ] Termination of Agreement

3. Address: _______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

4 Agency Name: OHCA Agency Number: 807 5. Financial Institution:

_________________________________________________________________________________

I, hereby authorize the State of Oklahoma Treasury, hereinafter called Treasury, to initiate credit entries for any

[ ] CHECKING or [ ] SAVINGS account indicated on voided check below and the financial institution named

above, hereinafter called depository, to credit any amount(s) due this medical provider by the State of

Oklahoma. This authority is to remain in full force and effect until Treasury has received written notification

from this provider of its termination in such time and in such manner as to afford Treasury and depository a

reasonable opportunity to act on it.

6. Signature: ______________________________________________ Date: ______________________________________________ ****************************************IMPORTANT********************************* For checking accounts, please attach a voided check here (deposit slips are not accepted).

For savings accounts, please attach an official document from your financial institution showing the bank transit routing and account numbers here.

Please return this completed form with your contract.

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SoonerCare 2005

ATTACHMENT E Guide to Immunization Requirements in Oklahoma

2004-2005

DAYCARE PRE-SCHOOL KDG thru 3rd 4th & 5th 6th 7th-11th 12th

4 DTP/DTaP/Td 4 DTP/DTaP/Td 5 DTP/DTaP/Td 5 DTP/DTaP/Td 3 DTP/Td 3 DTP/Td 3 DTP/Td 3 Polio 3 Polio 4 Polio 4 Polio 3 Polio 3 Polio 3 Polio 1 MMR 1 MMR 2 MMR 2 MMR 2 MMR 2 MMR 1 MMR 1-4 Hib 3 Hep B 3 Hep B 3 Hep B 3 Hep B 2 Hep A 2 Hep A 2 Hep A Varicella Varicella Varicella

2 Hep A (7th thru

10th)

• • Children in day care must be up-to-date for their age for the vaccines listed • • All Measles, mumps and rubella and varicella vaccine doses must have been administered on or after the child's

first birthday • • If the 4th dose of DTP/DTaP and/or 3rd dose of Polio are administered on or after the child's 4th birthday, then

the 5th dose of DTP/DTaP and/or 4th dose of Polio are not required • • Hepatitis A vaccine must be administered on or after the child's second birthday • • A parental history of a child having varicella disease is acceptable in lieu of varicella vaccine • • Hib vaccine is not required for students in pre-kindergarten or kindergarten through grade twelve, but is

required for children in day care • • Longer than recommended time periods between doses of multi-dose vaccines do not diminish the effectiveness

of these vaccines. It is not necessary to restart the series of any vaccine due to extended time periods between doses • • Children may be allowed to attend school if they have received the first dose in the series of any multi-dose

vaccine but must complete the series on schedule For further immunization information please call the Immunization Division, Oklahoma State Department of Health, 405-271-4073. Revised 11/2000

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ATTACHMENT F

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ATTACHMENT G ADDENDUM II

EPSDT SCREENING & NOTIFICATION DOCUMENT

This form is necessary for compliance with Article IV, Section 4.1(b & c) of the Intergovernmental

Agreement between OHCA and School Districts for EPSDT School-Based services. Child’s Name: ___________________________________________________________________________________________________ Last First M.I. Medicaid # ________________________ SSN# ____________________________________ Child’s Address:_____________________________________________________________________________________ Street Apt. # City State Zip Parent/Guardian: _____________________________________________________________________________________ Home Phone: ______________________ Work Phone: _____________________________________ ___________________________________________________________________________________________________ PARENT CONTACT: Name of Parent/Guardian contacted: _____________________________________________________________________ Date Parent Contacted: ________________________________________________________________________________ Name of Primary Care Provider: _______________________________________________________________________ Has Child received child health screening? ________________________________________________________________ ___________________________________________________________________________________________________ PRIMARY CARE PROVIDER/CASE MANAGER (PCP/CM) CONTACT Date of initial contact: ______________ Name of Person: ____________ Phone #: ___________________ Date of Scheduled appointment: _____________ Appointment Kept Y N (circle one) Referral for services: _________________________________________________________________________________ Signature of person making contact: _____________________________________________________________________ School District ______________________________________________________________________________________

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ATTACHMENT H ADDENDUM IX

EPSDT CONFIRMATION FORM (SCHEDULE G & H)

This form is necessary for compliance with Schedules G and H, and applicable Addenda pertaining to EPSDT and Early Intervention services. Child’s Name: ________________________________________________________________________

Last First M.I. Medicaid # ________________________ SSN# ______________________________ Child’s Address:_______________________________________________________________________ Street Apt. # City State Zip Parent/Guardian: _____________________________________________________________________ Home Phone: ______________________ Work Phone: ________________________ PARENT CONTACT: Name of Parent/Guardian Contacted: _____________________________________________________ Date Parent Contacted: ________________________________________________________________ Name of Primary Care Provider: _________________________________________________________ Has Child received child health screening? _________________________________________________ PRIMARY CARE PROVIDER/CASE MANAGER (PCP/CM) CONTACT: Date of initial contact: ______________ Name of Person: ____________Phone #: ______________ Date of Scheduled appointment: _____________ Appointment Kept Y N (circle one) Referral for services: ___________________________________________________________________ Signature of person making contact: ______________________________ _______________________________________________ County Health Department ____________________ Date

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ATTACHMENT I

SoonerCare Choice

CY 2005 EPSDT Bonus Payment Methodology January 1, 2005-December 31, 2005

Compliance Rate and Bonus Payment Methodology and Example

Compliance Rate Determination _CMS-416 Methodology (Refer to Example 1, Presented Below): Step 1: Total Individuals Eligible for ESPDT- List the total unduplicated number of all individuals under

the age of 21 determined to be eligible for EPSDT services, distributed by age and by basis of Medicaid eligibility. Unduplicated means that an eligible person is reported only once although he or she may have had more than one period of eligibility during the year.

Step 2a: State Periodicity Schedule - List the number of initial or periodic general health screenings

required to be provided to individuals within the age group specified according to the state's periodicity schedule. This information is provided in the example below.

Step 2b: Number of Years in Age Group - List the number of years included in each age group. Step 2c: Annualized State Periodicity Schedule - Divide the number in Step 2a by the number in Step 2b

for each age group. Step 3a: Total Months Eligibility - Enter the total months of eligibility for individuals in each age group

on Line 1 during the reporting year. Step 3b: Average Period of Eligibility - Divide the total months of eligibility by Step 1. Divide that

number by 12 and enter the quotient. This number represents the portion of the year that individuals remain Medicaid eligible during the reporting year, regardless of whether eligibility was maintained continuously.

Step 4: Expected Number of Screenings per Eligible - Multiply Step 2c by Step 3b per age group. Enter the product. This number reflects the expected number of initial or periodic screenings per child per year based on the number required by the state-specific periodicity schedule and the average period of eligibility.

Step 5: Expected Number of Screenings - Multiply Step 4 by Step 1 per age group. Enter the product. This reflects the number of initial or periodic screenings expected to be provided to the eligible individuals in Step 1.

Step 6: Total Screens Received - Enter the total number of initial or periodic screens furnished to eligible individuals.

Step 7: Screening Ratio - Divide the actual number of initial and periodic screening services received (Step 6) by the expected number of initial and periodic screening services (Step 5). This ratio indicates the extent to which EPSDT eligibles receive the number of initial and periodic screening services required by the State's periodicity schedule, adjusted by the proportion of the year for which they are Medicaid eligible.

Step 8: OHCA Required Compliance Rate - Enter the contractually required compliance rate per age group.

Bonus Payment Calculations (Refer to Example 1, Presented Below): Line 9 % Above Compliance - Example Line 7 minus Line 8. This will determine if the provider met

the OHCA compliance rate requirement. Line 10 Number of EPSDT Screens - This is the number from Example Line 6. Enter this number only if

the provider is above compliance for the age group. If the provider is below the required compliance rate enter zero (if Line 9 is negative).

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Bonus Payment Calculations (Refer to Example 1, Presented Below) Attachment I Continued: Line 11 Bonus Payment Per Screen - This is a fixed number to be determined by the OHCA and is based

on a percent of the actual cost of an EPSDT screen per age group. For example, if an EPSDT screen is reimbursed at $61.12 for the less than 1 year old age group, OHCA will pay an enhanced rate of $15.25 (an additional 25%) to providers who meet or exceed the compliance rate for the less than 1 year olds age group. (See Table 1: Bonus Payment Per Screen).

Line 12 Bonus Payment Amount Per Age Group - Multiply Example Line 10 by Example Line 11. This is the amount that will be paid to the provider for that specified age group.

Line 13 Total Potential Bonus Payment - Sum of age groups on Example Line 12. This is the potential total amount owed to the provider.

Line 14 Actual Bonus Payment - The final bonus payment cannot exceed 20% of the provider's annual capitation payment.

Please note, SoonerCare Choice provider EPSDT bonus payments in the aggregate shall not

exceed $1,000,000.00 Table 1: EPSDT Bonus Payment Per Screen Procedure Code Description Age Group Medicaid Allowable Bonus % Rate Enhanced EPSDT Blended Rate < 1 $ 61.12 @ 25% $ 15.28 EPSDT Blended Rate 1-5 $ 74.81 @ 25% $ 18.70 EPSDT Blended Rate 6-14 $ 78.72 @ 25% $ 19.68 EPSDT Blended Rate 15-20 $ 85.60 @ 25% $ 21.40 Example 1: EPSDT Bonus Payment Calculations Compliance Rate Calculations

(based on CMS-416 -methodology) < 1 1 2-5 6-14 15-20 Line 1: Total Individuals Eligible for EPSDT 212 181 486 796 87 Line 2a: Number of Required Screens 6 2 4 4.5 3 Line 2b: Number of Years in Age Group 1 1 4 9 6 Line 2c: Number of Expected Screen in One Year 6 2 1 0.5 0.5 Line 3a: Total Eligible Months 892 670 2693 4938 472 Line 3b: Average Period of Eligibility 0.35 0.31 0.46 0.52 0.45 Line 4: Expected Number of Screens Per Eligible 2.10 0.52 0.46 0.26 0.23 Line 5: Expected Number of Screens Per Group 446 112 224 206 20 Line 6: Total Screens Received 291 109 200 175 2 Line 7: Screening Ratio .65 .97 .89 .85 .10 Line 8: 2005 OHCA Required Compliance Rate .65 .65 .65 .65 .65 Bonus Payment Calculations Line 9: % Above Compliance 0 .32 .24 .20 (.50) Line 10: Number of EPSDT Screens from Line 6 - 109 200 175 - Line 11: Bonus Payment Per Screen $15.28 $18.70 $18.70 $19.68 $21.40 Line 12: Bonus Payment Amount Per Age Group $0 $2,038 $3,740 $3,444 $0 Line 13: Total Potential Bonus Payment $9,222 Line 14: 20% of Annual Capitation Payment $10,711 Line 15: Actual Provider Bonus Payment $9,222

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Oklahoma Health Care Authority

ATTACHMENT J DISCLOSURE OF OWNERSHIP

AND CONTROL INTEREST STATEMENT

Item I. Identifying Information (a) Name of Individual, Facility or Organization: _________________________________________________________________ (b) DBA Name: _________________________________________________________________ (c) Federal Tax Identification Number (TIN) or Social Security Number: _________________________________________________ (d) Check the entity type that best describes the structure of the enrolling provider entity. Check only one box.

For-Profit Corporation Non-Profit Corporation Partnership Government Owned Sole Proprietorship

(e) Is this entity chain affiliated? No Yes

Item II Ownership and Control Information (a) List the name, title, address, and SSN for each officer and/or individual who has direct or indirect ownership or controlling interest,

separately or in combination, amounting to an ownership interest of 5% or more of the provider entity. List the name, Tax ID (TIN), and address of any organization, corporation, or entity having direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more in the provider entity. Attach additional pages as necessary to list all officers, owners, management and ownership entities.

Name Title Address SSN/TIN Percentage _______________________________ _____________ ________________________________ ______________ ________

_______________________________ _____________ ________________________________ ______________ ________

_______________________________ _____________ ________________________________ ______________ ________

_______________________________ _____________ ________________________________ ______________ ________

_______________________________ _____________ ________________________________ ______________ ________

(b) List those persons named in Item II (a) that are related to each other (spouse, parent, child, or sibling). Name Relationship SSN ____________________________________________ _____________________________________ __________________________

____________________________________________ _____________________________________ __________________________

(c) List the name, title, address and social security number of each person with an ownership or control interest in any subcontractor in which the disclosing entity has direct or indirect ownership of 5 percent or more.

Name Title Address SSN/TIN Percentage _______________________________ _____________ ________________________________ ______________ ________

_______________________________ _____________ ________________________________ ______________ ________

(d) List the name, address and TIN of any other disclosing entity in which a person with an ownership or controlling interest in the

disclosing entity also has an ownership or control interest of at least 5% or more. Name Address TIN Percentage ___________________________________ ___________________________________ _________________ ____________

___________________________________ ___________________________________ _________________ ____________

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Oklahoma Health Care Authority ATTACHMENT J DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT (Page 2 of 3) Item III. Criminal Offenses (a) List the name, title, SSN and address of each officer and/or individual who has ownership or control interest in the

disclosing entity, or is an agent or managing employee of the disclosing entity and has been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid or the Title XX services program since the inception of those programs.

Name Title Address SSN (or TIN if organization) (b) List the name, title, social security number and address of an individual who has an ownership or controlling interest in the

disclosing entity and has been suspended or debarred from participation in Medicare, Medicaid or Title XX program since the inception of those programs.

Name Title Address SSN (or TIN if organization) Item IV. Status Changes (a) Has there been a change in ownership or control within the last year or is a change of ownership or control anticipated

within the year? No Yes (b) Is this facility operated by a management company or leased in whole or part by another organization?

No Yes

If "yes", list date of change in operations: __________________________________________________

(c) Have you increased your bed capacity by 10% or more or by 10 beds, whichever is greater, within the last year?

If "yes", when? ________________________________

Previous Number of Beds _______ Current Number of Beds ______ Date of Change ____________

(d) Has there been a change in Administrator, Director of Nursing or Medical Director within the last year?

If "yes", please check box below and list date.

Administrator Director of Nursing Medical Director Date: ___________________

Name of new Administrator, Director of Nursing or Medical Director: __________________________________________

(e) Has there been a past bankruptcy or do you anticipate filing for bankruptcy within a year?

No Yes

If "yes", when? ________________________________

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Oklahoma Health Care Authority ATTACHMENT J DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT (Page 3 of 3)

Item V. Board of Directors (a) List the name, title, social security number, and address of each of the members of the Board of Directors of the disclosing entity. Name Title Address SSN