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MANAGED LONG TERM SERVICES AND SUPPORTS PROVIDER AGREEMENTANY WILLING PROVIDERThis Agreement, together with the Appendices, attached hereto and incorporated herein byreference (“Agreement”) made as of the day of in the year of 2015, by andbetween Horizon Healthcare of New Jersey, Inc., a licensed New Jersey Health MaintenanceOrganization, d/b/a Horizon NJ Health (“Horizon NJ Health”), and , aprovider of (hereinafter referred to as “Provider” and or “Subcontractor”).WITNESSETH:WHEREAS, Horizon NJ Health is engaged in the arranging for the provision of health careservices for Members (as that term is defined below) who are enrolled in Horizon NJ Health; andWHEREAS, Horizon NJ Health has contracted with the Department of Human Services of theState of New Jersey (the “State Contract”) to arrange for the provision of comprehensive healthcare services (Horizon NJ Health’s “Managed Medicaid Program” to certain persons eligibleunder the State of New Jersey’s Medical Assistance Programs, Medicaid, NJ FamilyCare, DSNP and Managed Long Term Services and Supports (collectively referred to herein as“Medicaid Beneficiaries") who choose to become enrolled members of Horizon NJ Health(“Members); andWHEREAS, Horizon NJ Health provides health services, management and administrativeservices for the Managed Medicaid and NJ FamilyCare Programs; andWHEREAS, the Provider, is in the business of providing ; andWHEREAS, the parties mutually desire to enter into an Agreement whereby Provider will serveas a provider of , a Managed Long Term Services and Supports(“MLTSS”) as set forth in Appendix “A”, for Members, subject to the requirements as set forthin this AgreementNOW, THEREFORE, in consideration of the mutual covenants and understandings containedherein and of the mutual benefits expected to accrue to each of the parties to this Agreement, it ishereby agreed as follows:Page 1 of 42AWP v.2
1. DEFINITIONSAs used in this Agreement, the following words and phrases shall have the following meanings,unless the context otherwise requires:A. “Affiliate” shall mean, with respect to any party hereto, any Person that, directly orindirectly, through one or more intermediaries, controls, is controlled by or is undercommon control with such party. In addition, Horizon Healthcare of New Jersey, Inc. and“Horizon NJ Health” are interchangeable, and include Horizon Blue Cross Blue Shield ofNew Jersey, (“HMO”) and Horizon Insurance Company, and those Affiliates, subsidiaries,joint ventures or partnerships whose inclusion hereunder is the subject of prior notificationby Horizon NJ Health to Provider.B. “Any Willing Provider” shall mean, in accordance with the State Contract, any NewJersey-based nursing facility (NF), special care nursing facility (SCNF), assisted livingprovider (AL), community residential services (CRS) provider that serves residents withtraumatic brain injury, or long term care pharmacy that applies to become a network providerand complies with the Contractor’s provider network requirements shall be included in theContractor’s provider network to serve MLTSS Members. MLTSS Any Willing Providerstatus for NF, SCNF, AL and CRS will be for a two year period from the date that theservice comes into MLTSS, dependent upon available appropriation in each Fiscal Year.For NF, SCNF, AL and CRS that would mean that Any Willing Provider status expires onJune 30, 2016.C. “Care Management” shall mean a set of member-centered, goal-oriented and culturallyrelevant logical steps to assure that a member receives needed services in a supportive,effective, efficient, timely, and cost-effective manner. Care management emphasizesprevention, continuity of care, and coordination of care, which advocates for, and linksmembers to, services as necessary across providers and settings. At a minimum, caremanagement functions shall include, but are not limited to:1.Early identification of members who have or may have special needs,2.Assessment of an member’s risk factors,3.Development of a Plan of Care,4.Referrals and assistance to ensure timely access to providers,5.Coordination of care actively linking the member to providers, medical services,residential, social, and other support services where needed,6.Monitoring the provision of services contained in the Plan of Care,7.Continuity of care, andPage 2 of 42AWP v.2
8.Follow-up and documentation.D. “Care Manager” shall mean a Horizon NJ Health employee or employee of asubcontracted vendor who has been assigned to Member.E. "Clean Claim" shall mean a claim that has no defect or impropriety, including any lackof required substantiating documentation or particular circumstance requiring specialtreatment that prevents timely payment being made on the claim. A "clean claim" is aclaim, or part of a claim, which can be paid exactly as submitted without the need forfurther documentation or explanation.F. “Critical Incident,” as more fully set forth in Appendix “D”, shall mean an occurrenceinvolving the care, supervision, or actions of an enrollee that is adverse in nature or hasthe potential to have an adverse impact on the health, safety, and welfare of the enrollee orothers. Critical Incidents also include situations occurring with staff or individuals oraffecting the operations of a facility/institution/school.G. "Coordination of Benefits" shall mean the existence of benefits for the payment ofServices for Members other than those provided by the Members’ Medicaid Plan. Theprogram under which those benefits are provided may be primary or secondary, and mayor may not have any financial responsibility for charges incurred by Members for CoveredServices.H. "Copayments" shall mean payments which are the responsibility of a Member for theprovision of certain Covered Services in accordance with the applicable Medicaid Plan.I. “Covered Services” shall mean those medically necessary medical and hospital services,supplies, and Managed Long Term Services and Supports as set forth in the State Contractand in Appendix “A” which shall be no broader or narrower than the services to whichMedicaid Beneficiaries are entitled under the New Jersey Medical Assistance Programunless expressly provided in the State Contract.J. “Fee For Service Payment” shall mean the fee for service payments set forth inAppendix “B” for the Covered Services which are the set forth in Appendix “B” thatProvider has agreed to supply to Members.K. “Home and Community-Based Services” (HCBS) shall mean those services above Stateplan limits that are provided as an alternative to long-term institutional services in anursing facility. HCBS includes personal care assistance and medical day care when theyare above the limits established under New Jersey's Title XIX State Plan. HCBS areprovided to individuals who meet MLTSS eligibility requirements and reside in thecommunity or in certain community alternative residential settings.Page 3 of 42AWP v.2
L. “Medical Emergency” shall mean health care services required to treat a medicalcondition manifesting itself by acute symptoms of sufficient severity including, but notlimited to, severe pain, psychiatric disturbances and/or symptoms of substance abuse suchthat a prudent layperson who possesses an average knowledge of health and medicinecould reasonably expect the absence of immediate medical attention to result in: placingthe health of the individual (or, with respect to a pregnant woman, the health of thewoman or her unborn child) in serious jeopardy; serious impairment to bodily functions;or serious dysfunction of a bodily organ or party. With respect to a pregnant woman whois having contractions, an emergency exists where there is inadequate time to affect a safetransfer to another hospital before delivery; or the transfer may pose a threat to the healthor safety of the woman or the unborn child.M. "Medically Necessary" shall be defined as set forth in Appendix “C”, which is attachedhereto and incorporated herein by reference.N. “Member” shall mean a Medicaid Beneficiary who chooses to become enrolled as amember of Horizon NJ Health’s Managed Medicaid Program; shall also mean an“enrollee.”O. “Managed Long Term Services and Supports” (MLTSS) shall mean a program thatapplies solely to individuals who meet MLTSS eligibility requirements and encompassesthe New Jersey Medicaid Plan A benefit package, HCBS and institutionalization for longterm care in a nursing facility or special care nursing facility. MLTSS Covered Servicesare defined in Appendix “A”.P. “NJ Choice Tool” shall mean the assessment instrument developed by inter-RAI,consisting of a core set of screening, clinical and functional status elements, includingcommon definitions and coding categories used to conduct a standardized assessment todetermine eligibility for nursing facility level of care services, and MLTSS eligibility,pursuant to N.J.A.C.8:85-2.1.Q. "Participating Provider" shall mean a health care provider or services provider who hasentered into a participating provider agreement with Horizon NJ Health.R. "Payment" shall mean the amount payable to a provider for medically necessary CoveredServices, which shall be either of the following type: (i) Provider’s billed charges or theHorizon NJ Health's applicable fee, whichever is less. Provider acknowledge that the typeof Payment generally and the type of Payment for any particular Covered Service isdetermined by Horizon NJ Health and is subject to revision from time to time.S. “Plan of Care” (POC) shall mean a written plan for services developed to address allidentified service needs of MLTSS members.T. "Precertification or Authorization" means the process by which Horizon NJ Healthdetermines in advance whether or not Covered Services are Medically Necessary andPage 4 of 42AWP v.2
Appropriate, or it shall mean the authorization provided to Provider by Horizon NJ Healthverifying that Covered Services are Medically Necessary and Appropriate.U. "Utilization Management/Quality Improvement ("UM/QI") Protocols" shall meanthe programs established by Horizon NJ Health to monitor and enhance the quality ofhealth care services provided to Members and those methodologies used to improve theeffective, efficient use of the health care delivery system and Covered Services including,but not limited to, pre-review, concurrent review and retrospective review as well asdischarge planning, as applicable, consistent with the State Contract.2. OBLIGATIONS OF PROVIDERA. Licensure and Privileges. Provider shall, during the entire term of this Agreement,maintain a current, unrestricted valid professional or business license, certification oraccreditation, as required by the Provider’s specialty. Provider shall notify Horizon NJHealth immediately if Provider’s applicable license, certification or accreditation topractice or deliver Covered Services in any State, are voluntarily withdrawn, restrictedtemporarily or permanently, or suspended or revoked for any reason. Provider shall alsonotify Horizon NJ Health immediately in the event of a revocation, suspension,debarment and/or investigation of Provider’s or Provider’s employee’s status as aparticipant in a State Medicaid Program or in the federal Medicare or health careProgram. Finally, Provider assures Horizon NJ Health that no employee or subcontractorengaged in providing Covered Services to Members has plead guilty to or is convicted ofa criminal offense that prevents the employee or subcontractor under New Jersey lawfrom providing direct care services to Members, and Provider agrees to notify HorizonNJ Health immediately upon notice of same. Provider hereby represents that Provider,nor any of its employees, have not in the past been the subject of a revocation,suspension, debarment and/or investigation of its participation status in any StateMedicaid program or the federal Medicare program or had participation in such programsrevoked, suspended or debarred.Provider shall check the OIG’S “List of Excluded Individuals/Entities,” the GeneralServices Administration (GSA) database of excluded individuals/entities, and the State ofNew Jersey’s database of suspended or excluded individuals/entities to determinewhether any employee or contractor of Provider has been suspended or excluded fromparticipation in Medicaid, Medicare or any other federal program. Provider shallimmediately notify Horizon NJ Health in writing if Provider or any employee orcontractor is suspended or excluded from Medicaid, Medicare or any other federalprogram. Provider shall prohibit any employee or contractor that has been suspended orexcluded from Medicaid, Medicare or any other federal program from doing any workdirectly or indirectly related to services furnished under this Agreement to Members. .Should the individual be reinstated by the U.S. Department of Health and HumanServices, Office of Inspector General’s (“OIG”) or the New Jersey Medicaid Program,then the Provider shall disclose same to Horizon NJ Health, with evidence ofreinstatement, prior to performing services under this Agreement.Page 5 of 42AWP v.2
Provider and all employees, staff members, contractors and agents employed by and/orassociated with Provider, for the term of this Agreement and for any renewal terms, shallmeet all credentialing and re-credentialing requirements as may be established by HorizonNJ Health of which Provider is notified including, without limitation, those set forth in theState Contract from time to time. Such requirements shall include submitting a completedDisclosure Form, as required by the State attached as Appendix F.Provider agrees to verify the licensure, certification and credentials of all personsproviding care or supervising the care provided to Members in accordance with therequisite or applicable licensing or accrediting agencies, bodies or entities, or thestandards established by JCAHO and to submit to Horizon NJ Health, on request,verification of such licensure, certification or credentials.This Agreement shall not impose any obligations upon Provider which require Provider toviolate any law, statute, rule or regulation governing the licensure certification oraccreditation of the Provider.B. Criminal History Background Checks. Provider agrees to conduct pre-employmentcriminal history background checks on any employee or subcontractor with direct physicalaccess to Members, including but not limited to aides, homemakers, general contractorsand other chore service providers.Provider shall have policies and procedures that demonstrate compliance with Staterequirements to have a pre-employment criminal history check and/or backgroundinvestigation on all staff members or subcontractors. Provider agrees to allow HNJH staffunannounced access to view a sample of employee and subcontractor records to verifycompliance with this requirement.C. Authority to Conduct Business in New Jersey. The Provider asserts that it and anysubcontracted business entity has: (i) the authority to conduct business in New Jersey andpossesses evidence of authority such as a New Jersey Tax Certification or Trade NameRegistration or Business Registration; and (ii) has any license required by law to engage inthe service or provide furnishings, appliances and equipment as applicable; and shallrequire evidence of required, qualified product or business insurance and bonding.D. Provider Services to Members. In accordance with this Agreement, Provider shallprovide only those MLTSS for which Provider is credentialed to provide as set forth inAppendix A AND which have been included in the Plan of Care as developed jointly bythe Member and Member’s assigned Care Manager. Services shall be provided in acompetent, professional and ethical manner, in accordance with applicable licensing oraccrediting agencies, bodies or entities, using appropriate skill and diligence to allMembers who have been referred to Provider.In an Emergency, Provider shall immediately proceed to render the facility’s emergencyplan or Medically Necessary and Appropriate services to the Member, as appropriate forthat facility. Provider shall also contact the Member’s Primary Care Physician (if any) andPage 6 of 42AWP v.2
the Horizon NJ Health Care Manager within twenty-four (24) hours or the next businessday of the treatment of the Emergency.E. Non-Discrimination. In rendering care to Members, Provider agrees not to differentiateor discriminate from Provider’s other patients/clients in the type or manner of servicesprovided because they are Horizon NJ Health Members. Provider agrees to provide thesame level of health care and services, or higher, to Medicaid enrollees as it does toenrollees under private or group health care coverage contracts.F. Sub-contracted Services . In the event Provider desires to subcontract with anothervendor to manage or control the delivery of Covered services to all Members or residentsof the health care facility, Provider shall notify Horizon NJ Health. Provider shall beresponsible for ensuring performance by its subcontractors in a manner consistent withthis Agreement including, but not limited to, the inclusion in each such subcontract aprovision stating that such vendor shall not bill Members, Horizon NJ Health or the Stateof New Jersey for any services except as expressly permitted in this Agreement. A breachor default by a subcontractor may be treated as a breach or default by Provider and may besubject to termination pursuant to Article 4. In addition to any other obligation hereunder,Provider shall make available to the State of New Jersey any and all contractual orapplicable financial records of Provider related to Provider’s subcontractors.G. Provider Conduct. Provider shall conduct, and shall cause its employees, contractors,staff and agents to conduct, operations in compliance with all applicable federal, State andlocal laws , rules regulations and guidelines, and the rules, regulations, policies andprocedures of Horizon NJ Health for which provider has been given reasonable notice.Nothing in this Agreement shall provide or be construed to provide financial incentives toProvider for withholding MLTSS Covered Services that have been authorized by theMember’s MLTSS Care Manager as contained in the established Plan of Care. Nothing inthis Agreement shall require Provider to violate the statutes or rules governing licensure,certification or accreditation of the Provider. Nothing in this Agreement shall be construedto restrict the ability of the Provider, or its employees or staff, to communicate openlywith a Member about all appropriate testing, treatment and service options.H. Federal and State Funds. Provider acknowledges that Horizon NJ Health is receivingFederal and State funds under the Medicaid Program, and that as a contractor withHorizon NJ Health as to the Medicaid Program, Provider is subject to all laws andregulations applicable to entities receiving Federal funds, including, for example, the CivilRights Act of 1964 and the Americans with Disabilities Act. Provider further agrees toparticipate in, and cooperate with, independent quality review, improvementorganizations, and Medicaid appeals or Fair Hearings, as to Covered Services provided toMembers under the Medicaid Program.I. Coordination of Benefits. Provider acknowledges that, in accordance with federal andState laws and in particular N.J.S.A. 30:4D-6, Medicaid is the payor of last resort.Page 7 of 42AWP v.2
Provider shall assist with processing forms required to pursue Coordination of Benefitswith other health care plans and coverages (including without limitation Medicare,workers’ compensation, duplicate coverage and personal injury liability). Provider furtheragrees to make diligent efforts to identify, and collect information concerning, such otherhealth care plans and coverages at the time of admission or service and, will first seekpayment from such other plan or coverage as required by State Contract or according tothe applicable Horizon rules for Coordination of Benefits that shall be consistent withState requirements. Provider agrees to seek reimbursement only for those services forwhich Provider is licensed and/or certified to provide.J. Compliance with Horizon NJ Health Requirements, Policies, and Procedures.Provider agrees to provide MLTSS in conformity with and to cooperate and comply withthe requirements, policies, procedures and protocols established by and acceptable toHorizon NJ Health, or its designees, including, but not limited to, MLTSS CareManagement, Quality Improvement/Risk Management, Utilization Management andHorizon NJ Health 's complaint, grievance and appeal process. Provider agrees tocooperate with Horizon NJ Health in meeting accreditation requirements of the NationalCommittee for Quality Assurance (NCQA) or such other organizations to which HorizonNJ Health might apply for accreditation. Provider shall also reasonably cooperate andcomply with and abide by the Horizon NJ Health’s MLTSS Care Management proceduresof which the Provider acknowledges receipt, and which are set forth in the ProviderManual and on the Horizon NJ Health web site, so long as these do not conflict with NewJersey law or regulations.K. Process for Pre-Authorization of MLTSS. All Member’s determined to be eligible toreceive MLTSS shall be assigned a HNJH Care Manager who will conduct a face to faceassessment of the Member for the purpose of identifying Member’s strengths, needs andgoals, and to develop a Plan of Care outlining all services, including MLTSS HCBS andNursing Facility Services when appropriate, to be provided which capitalize on Member’sstrengths to meet identified needs and achieve goals. Care Manager shall promptly issuean Authorization number to Provider prior to the commencement of services by Provider.The authorization shall cover all periods of time from the commencement of Member’sadmission to the facility where such care has been deemed medically necessary. Provideragrees to provide only those services included in the Member’s Plan of Care andauthorized by the Care Manager. If provider feels that a change in Member’s conditionwarrants a change in type, frequency, amount or duration of services, Provider shall alertMember’s assigned Care Manager to request a re-assessment to determine if Plan of Careshould be amended.It is understood and agreed by Provider that issuance of an Authorization for benefitsrepresents an acknowledgment by Horizon NJ Health that, based upon informationprovided, MLTSS are necessary and appropriate and is not an assurance or guarantee ofpayment of a claim, and is additionally dependent on eligibility, as verified by theProvider. If Horizon NJ Health has provided Authorization for MLTSS, Horizon NJHealth shall not deny payment of a claim on grounds that MLTSS are not necessary andAppropriate, except in cases where there was material misrepresentation or fraud. ThePage 8 of 42AWP v.2
MLTSS Authorization number assigned by HNJH Care Manager MUST accompany anybilling information submitted by Provider to Horizon NJ Health. Only those MLTSSincluded in the Plan of Care for which Provider has received an authorization numbershall be submitted for payment.L. Critical Incident Reporting. Provider agrees to report all Critical Incidents, as defined inAppendix “D”, in accordance with the requirements outlined in Appendix “D ”.M. Service Verification. For those Providers who provide services in the home, orresidentialsetting, the following Service Verification procedures shall apply:Providers shall be required to call Horizon NJ Health in the event they arenot able to perform a service.If the provider is unable to complete a service, the provider must callHorizon NJ Health at least (one) 1 business day, but no later than (four) 4hours prior to the scheduled service.Horizon NJ Health shall have the right to perform monthly audits ofservice logs to validate that services are being performedFailure to abide by this clause or consistent failure in providing servicescan be considered a breach and can result in termination of thisAgreement.N. Administrative Responsibilities. Provider agrees to maintain, utilize, submit and providecopies of such medical records, supply forms, encounter logs, financial, administrative orother records, related to or in connection with the services provided to Members, inaccordance with accepted standards of practice and the requirements of the State of NewJersey, or the State Contract. Copies of medical records shall be provided free of chargeand in a timely manner as may be necessary for compliance by Horizon NJ Health withState and federal law, as well as for program management purposes. Provider also agreesto permit Horizon NJ Health, State and federal officials and accreditation agencies as wellas their agents to inspect, at reasonable times, Provider’s facilities pursuant to the MLTSSCare Management and Quality Improvement Protocols.Provider agrees to comply, cooperate and participate with Horizon NJ Health requirementsof which Provider is or has been notified including, without limitation, all reasonableutilization management policies and procedures, quality of care review, internal andexternal audit programs and accreditation programs established by Horizon NJ Health oradministered by Horizon NJ Health, the requirements of all State and federal governmentagencies and applicable private accrediting organizations. Provider agrees to be bound byall final determinations rendered under all such programs, in accordance with the appealsprocess mandated by State law. Provider further agrees to comply with and be bound bythe provider complaint and appeals process set forth in the Provider Manual.Provider agrees to meet all of the requirements of the Horizon NJ Health related to theservices that the Provider is contracting to perform, consistent with State requirements forPage 9 of 42AWP v.2
the service. Provider agrees that Horizon NJ Health may use Provider’s name, address,phone number, type of practice, hospital affiliation(s), as may be applicable, and anindication of Provider’s willingness to accept additional Members in Horizon NJ Health 'sroster of participating providers and other Horizon NJ Health materials.The provisions of this Section shall survive the termination or expiration of thisAgreement.O. Insurance. Provider agrees, at Provider’s sole expense, to maintain professional and/orbusiness liability insurance as outlined in Appendix “B”. Such coverage shall be in suchform and amounts acceptable to Horizon NJ Health, and in an amount sufficient forProvider’s anticipated risk. Provider shall notify Horizon NJ Health immediately in theevent of any termination or change in such coverage. Provider shall provide Horizon NJHealth with evidence that such insurance coverage is in force on each anniversary date ofthis Agreement.The parties agree to adhere to and be bound by the common law and statutory principles ofindemnification and contribution as they exist in the State of New Jersey, and shall extendsuch indemnification to the State of New Jersey and Members in the event of a disputebetween Provider and Horizon NJ Health. The provisions of this paragraph shall survivethe termination or expiration of this Agreement.P. Records and Confidentiality. Provider shall maintain a medical record or recordapplicable to the service provided, for each Member in accordance with industry standards,and State laws and regulations applicable to the service. Medical records shall bemaintained by Provider for no less than ten (10) years from the date of service and allpending matters are closed, whichever is later. For Members that are eligible through theNew Jersey Division of Children and Families, records must be kept in accordance withapplicable laws regarding reports of abused children and consistent with the need to protectthose Members' confidentiality. Business records shall be maintained in accordance withSection M of the State Required Regulatory Language at Appendix E for a period of five(5) years. If an audit, investigation, litigation, or other action involving the records isstarted before the end of the retention period, the records must be retained until all issuesarising out of the action are resolved or until the end of the retention period, whichever islater. Horizon NJ Health and Provider agree that all Members’ medical records shall betreated as confidential so as to comply with all Federal and State laws and regulationsregarding the confidentiality of patient records, including but not limited to the HealthInsurance Patient Protection Act (HIPAA), but that Horizon NJ Health, and the State ofNew Jersey or its representative(s) and Provider shall have a mutual right to reviewMembers medical records as well as timely and appropriate communication of patientinformation in order to perform their respective duties hereunder for the benefit ofMembers. Provider agrees that Member’s consent to release those records contained in theState of New Jersey’s enrollment form is satisfactory, or as otherwise provided byapplicable law. Horizon NJ Health as well as State and federal regulatory authorities andaccreditation agencies shall have the right, after reasonable notice to Provider, to inspect allbooks and records, including but not limited to medical records, maintained by Provider,Page 10 of 42AWP v.2
pertaining to health care services provided to Members. In addition, in the event a Memberis transferred or disenrolls, Provider shall provide a copy of Member's medical recordswithout charge to Member's new Provider upon the request of Horizon NJ Health orMember in a timely manner as appropriate to the Member's health status and efficientprovision of care.The provisions of this Section shall survive the termination or expiration of thisAgreement.Q. Off-Shore Services. Provider agrees to
MANAGED LONG TERM SERVICES AND SUPPORTS PROVIDER AGREEMENT ANY WILLING PROVIDER This Agreement, together with the Appendices, attached hereto and incorporated herein by reference ("Agreement") made as of the _ day of _ in the year of 2015, by and between Horizon Healthcare of New Jersey, Inc., a licensed New Jersey Health .
