Health Choice Arizona

ATTACHMENT B-3

SCOPE OF SERVICES AND REIMBURSEMENT

FEE-FOR-SERVICE DENTIST

SECTION 1 - SCOPE OF SERVICES

1.1 SUBCONTRACTOR shall provide authorized Dental COVERED SERVICES under the Health Choice Arizona, Inc (HCA) contract with AHCCCS. These services shall be paid for by HCA, when provided or arranged for by SUBCONTRACTOR in accordance with the terms and conditions of this Agreement and when such services are within the normal scope of practice of SUBCONTRACTOR.

1.2 HCA recognizes SUBCONTRACTOR is a Federally Qualified Health Center (FQHC), and is therefore covered under the Federal Tort Claims Act (FTCA)

SECTION 2 - FEE-FOR-SERVICE REIMBURSEMENT

2.1 For authorized Dental COVERED SERVICES provided to MEMBERS, SUBCONTRACTOR and employed dentists shall be reimbursed at 100% of the prevailing AHCCCS fee schedule. Affiliated Practice Dental Hygienists shall be reimbursed at 100% of the prevailing AHCCCS Dental Hygienists fee schedule.

SECTION 3 - BILLING AND REPORTING REQUIREMENTS

3.1 SUBCONTRACTOR shall file, regardless of reimbursement method, claims data on a valid claim form OR via electronic method as approved by HCA and in accordance with Policies and the applicable provisions of this Agreement, within six (6) months from the date of service. SUBCONTRACTOR shall utilize the most current diagnostic and procedure coding guidelines, including International Classification of Diseases (ICD), American Medical Association Current Procedural Terminology (AMA CPT), Health Care Financing Administration Common Procedural Coding System (HCPCS), National Drug Code (NDC), Diagnostic Statistical Manual (DSM), Current Dental Terminology (CDT), Uniform Billing Data Elements (UB-92) Specification Manual, and State identified CPT/HCPCS codes as directed by HCA.

Failure to submit claims and if applicable, Encounter data within the prescribed time period may result in payment delay and/or denial. All SUBCONTRACTOR billing must follow recognized national billing practices.

HCA will evaluate all claims and payments for Covered Services in light of claim information on the condition treated and services or items provided and current AMA CPT or ADA CD guidelines, national bundling edits including the Correct Coding Initiative, modifier usage, global surgery rules, multiple procedure reductions, unit limitations, age/gender appropriateness and other reimbursement or utilization criteria, and reimburse or adjust reimbursement for Covered Services in accordance with the information and guidelines and criteria.

PROVIDER shall use its best efforts to submit claims and if applicable, Encounter data electronically. If claims and/or Encounter data are submitted electronically, they shall be submitted in compliance with HCA requirements, Applicable Law, including HIPAA regulations and Policies.

3.2 HCA adjudicates ninety-five percent (95%) of authorized clean claims that include all necessary information for processing (i.e., a “clean claim”) within thirty (30) days of receipt. A clean claim is a claim that may be processed without obtaining additional information from the provider of service or from a third party; but does not include claims under investigation for fraud or abuse or claims under review for dental necessity.

3.3 At a minimum, all claims shall provide the following information and data:

3.3.1 Members’ Name, Sex, and Date of Birth;

3.3.2 Member’s AHCCCS I.D. Number

3.3.3 Procedure Code (Current CDT codes);

3.3.4 Date(s) of Service

3.3.5 HCA Prior Authorization Number (if applicable);

3.3.6 SUBCONTRACTOR’ Name, Address and Authorized Signature

3.3.7 Subcontractor NPI number in the appropriate box of the ADA claim form ..

3.3.8 Explanatory Benefits (refer to Section 5 of this attachment for more details);

3.3.9 Rates and Charges (usual and customary billing charges);

3.3.10 Failure to submit any of the above information and data within the prescribed time period may result in payment delay and/or denial;

3.3.11 Claims are to be mailed and addressed to the HCA office at the following address:

Health Choice Arizona

410 N. 44th St., Ste. 500

Phoenix, AZ 85008

3.4 HCA shall be required to pay interest on late payments. Late claim payments are those that are paid after 45 days of receipt of the clean claim. In grievance situations, interest shall be paid back to the date interest would have started to accrue beyond the applicable 45 day requirement. Interest shall be at the rate of 10 percent per annum.

3.5 HCA shall not recoup monies from a provider later than twelve (12) months after the date of original payment on a clean claim, without prior approval from AHCCCSA, unless the recoupment is a result of fraud, reinsurance audit findings, data validation or audits conducted by the AHCCCSA Office of Program Integrity.

3.6 HCA shall reimburse providers who previously had recouped dollars if the following situations apply:

3.6.1 Provider was subsequently denied payment by the primary insurer based on timely filing limits; or

3.6.2 Lack of prior authorization with the primary insurer; and

3.6.3 The member failed to disclose additional insurance coverage other than AHCCCS.

SECTION 4 - COORDINATION OF BENEFITS

4.1 HCA is the payer of last resort and SUBCONTRACTOR shall identify and bill other third-party carriers or insurers first.

4.2 If a Member has third-party coverage, including but not limited to Part A or Part B Medicare, SUBCONTRACTOR agrees to identify and seek such payment before submitting claims to HCA.

4.3 Claims involving third parties shall be filed in accordance with the following:

4.3.1 SUBCONTRACTOR shall include a complete copy of the other third-party carrier’s explanation of benefits (EOB) or remittance advice (RA) when submitting a claim for the balance due under coordination of benefits. Such claim(s) for any balance due must be received by HCA within thirty (30) days from the date of remit from the primary carrier or six (6) months from date of service, whichever is less.

4.3.2 For HCA Medicare Members, the difference between the Medicare allowed charges, as shown in the explanation of Medicare reimbursement received, will be eligible for payment by HCA. Payment by HCA will be based upon the HCA fee schedule, less the Medicare allowed amount. HCA payment of beneficiary co-insurance, plus any applicable deductible, will constitute payment in full to SUBCONTRACTOR.

4.3.3 For HCA non-Medicare Members, the allowed amount will be based upon the HCA fee schedule, less the allowed amount of the other third-party carrier(s); the balance of which will be paid by HCA as coordination of benefits.

4.3.4 In situations where SUBCONTRACTOR has not received notification from the primary payer, SUBCONTRACTOR may submit the claim without the EOB/EOMB and it must be received by HCA within the prescribed initial submission deadline of six (6) months. HCA will deny the claim for failure to submit the EOB/EOMB thereby allowing the SUBCONTRACTOR to resubmit the claim with the EOB/EOMB within twelve (12) months from the date of service.

SECTION 5 - CLAIMS RESUBMISSION

5.1 SUBCONTRACTOR may resubmit claims that have been denied or adjudicated by HCA but they must be received by HCA within twelve (12) months from the date of service.

5.2 HCA will re-adjudicate claims re-submitted by SUBCONTRACTOR only if initial claim had been filed within the prescribed submission timeframe

5.3. Claims re-submissions shall be designated as such and shall consist of the following:

1. Copy of claim

2. Copy of HCA remit

3. Supporting documentation; and

4. Written explanation as to reasons for resubmission

5.4 Resubmitted claims are to be addressed and mailed to the HCA address listed in Section 3 of this Attachment.

SECTION 6 - CLAIM DISPUTE

6.1 The Claim Dispute Process: HCA processes Claim Disputes in accordance with established laws, rules, and procedures set forth by AHCCCS (ARS §36-2903.01, A.A.C. R9-34-401 et. seq.).

6.2 Right to File a Claim Dispute: SUBCONTRACTOR has the right to file a written Claim Dispute in response to any adverse action or decision made by HCA. The AHCCCS grievance process described as Arizona Administrative Code R9-34-401 et. seq. is the manner through which SUBCONTRACTOR may challenge an adverse decision, action or policy of HCA. The parties agree to attempt to resolve all disputes informally prior to initiating a formal grievance; however, all timeliness and other requirements to initiate a written Claim Dispute shall apply.

HCA encourages SUBCONTRACTOR to exhaust all other means of resolution before using the Claim Dispute process. Towards this end, SUBCONTRACTOR may contact HCA to resolve claims reimbursement issues informally.

6.3 Filing a Claim Dispute: If SUBCONTRACTOR is unable to resolve a claim issue, he/she may file a written Claim Dispute. To file a Claim Dispute, SUBCONTRACTOR must notify HCA in writing. Per AHCCCS rules [ARS 36-2903.01/R9-34-405], HCA will entertain any Claim Dispute within twelve months after the date of service, within twelve months after the date that eligibility is posted or within sixty days after the date of the denial of a timely claim submission, whichever is later. HCA shall deny Claim Disputes received outside of these timeframes. A timely claim submission is defined as claims for system covered services that are initially submitted within six months of the date of the service for which payment is claimed or after the date that eligibility is posted, whichever date is later, or that are submitted as clean within twelve months of the date of service for which payment is claimed or after the date that eligibility is posted, whichever date is later.

6.4 SUBCONTRACTOR must include a cover letter with the requester’s name, address and telephone number. The cover letter must include the factual or legal basis for filing the Claim Dispute and the relief requested, to include specifically why SUBCONTRACTOR disagrees with the action initiated by HCA. A copy of the claim and all supporting documentation to support the billed charges in question must be included if it is a billing issue. HCA shall deny a Claim Dispute if the factual or legal basis is not detailed. SUBCONTRACTOR agrees to submit all written Claim Disputes to the Compliance Department at the address listed below:

Health Choice Arizona

Attention: Compliance Department

410 N. 44th St., Ste. 900

Phoenix, AZ 85008

6.5 HCA agrees that once SUBCONTRACTOR has submitted a written Claim Dispute to HCA, HCA will send an acknowledgment letter by regular mail. HCA further agrees to respond to all Claim Dispute requests by SUBCONTRACTOR within thirty (30) days from the date that HCA received the written Claim Dispute. HCA agrees to mail a final written decision via Certified Mail. If an extension is necessary, HCA will forward notification.

6.6 SUBCONTRACTOR may file a request for State Fair Hearing if SUBCONTRACTOR is not satisfied with HCA’s decision. State Fair Hearing Requests must be received by HCA no later than thirty (30) calendar days from the date the SUBCONTRACTOR receives HCA’s Claim Dispute decision. The State Fair Hearing request only needs to state that the requester does not agree with the decision of HCA. HCA will forward a copy of Subcontractor’s request the AHCCCS Office Legal Assistance within five (5) working days. AHCCCS may either issue an informal decision or schedule a hearing.

HCA Dental Agreement Oct’11/HCG Dental Agreement Jul’12 Page 1 of 5

ATTACHMENT B-4

HEALTH CHOICE GENERATIONS

SCOPE OF SERVICES AND REIMBURSEMENT

FEE-FOR-SERVICE DENTAL AGREEMENT

SECTION 1 - SCOPE OF SERVICES

1.1.1 SUBCONTRACTOR shall provide authorized COVERED SERVICES under the Health Choice Arizona, Inc (HCA) contract with CMS dba Health Choice Generations (HC Generations). These services shall be paid for by HC Generations, when provided or arranged for by SUBCONTRACTOR in accordance with the terms and conditions of this Agreement and when such services are within the normal scope of practice of SUBCONTRACTOR.

1.2 HCA recognizes SUBCONTRACTOR is a Federally Qualified Health Center (FQHC), and is therefore covered under the Federal Tort Claims Act (FTCA)

SECTION 2 - FEE-FOR-SERVICE REIMBURSEMENT

2.1 For COVERED SERVICES provided to Health Choice Generations MEMBERS, SUBCONTRACTOR shall be reimbursed less any applicable Co-payments, Deductibles, and Coinsurance, at 100% of the prevailing AHCCCS Fee Schedule or billed charges, whichever is less. Affiliated Practice Dental Hygienists shall be reimbursed at 100% of the prevailing AHCCCS Dental Hygienists fee schedule.

SECTION 3 - BILLING AND REPORTING REQUIREMENTS

Failure to submit claims and if applicable, Encounter data within the prescribed time period may result in payment delay and/or denial. All SUBCONTRACTORS billing must follow recognized national billing practices.

HC Generations will evaluate all claims and payments for Covered Services in light of claim information on the condition treated and services or items provided and AMA CPT-4 guidelines, national bundling edits including the Correct Coding Initiative, modifier usage, global surgery rules, multiple procedure reductions, unit limitations, age/gender appropriateness and other reimbursement or utilization criteria, and reimburse or adjust reimbursement for Covered Services in accordance with the information and guidelines and criteria.

PROVIDER shall use its best efforts to submit claims and if applicable, Encounter data electronically. If claims and/or Encounter data are submitted electronically, they shall be submitted in compliance with HC Generations requirements, Applicable Law, including HIPAA regulations and Policies.

3.1 HC Generations adjudicates ninety-five percent (95%) of authorized clean claims that include all necessary information for processing (i.e., a “clean claim”) within forty-five (45) days of receipt. A clean claim is a claim that may be processed without obtaining additional information from the provider of service or from a third party, but does not include claims under investigation for fraud or abuse or claims under review for medical necessity.

3.3 At a minimum, all claims shall provide the following information and data:

3.3.1 Members’ Name, Sex, and Date of Birth;

3.3.2 Member’s Health Choice Generation I.D. Number;

3.3.3 Procedure Code (Current CDT codes);3.3.5 Date(s) of Service