10/18/2000 Enrollment
Clelllllllle
CircUI coon
Danny L. Kolhage
Phone: 805-292-S650 Fax: 805-296-3616
Memnrandum
To:
Reggie Paras, Director
Public Safety Department
From:
Isabel C. DeSant~ C /7:
Deputy Clerk ...
Tuesday, November 7, 2000
Date:
At the Board of Commissioners' Meeting on October 18, 2000, the Board granted
approval and authorized execution of the following:
1. Medicare EDI Enrollment Form in regards to ambulance billing services.
2. Non-Institutional Medicaid Provider Agreement in regards to ambulance
billing services.
3. Florida Medicaid Provider/Billing Agent Agreement in regards to
ambulance billing services.
4. Agency for Health Care Administration Electronic Claims Submission
Agreement in regards to ambulance billing services.
5. Agreement between Monroe County and the City of Key West concerning the
issuance and utll1zation of automated external defibrillators
Attached are fully-executed duplicate originals of the above documents for your
handling.
Should you have any questions concerning this matter please feel free to contact
this office.
Copies: Finance
County Attorney
File
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The provider agrees to the following provisions for submitting Medicare claims electronically to HCF A or to 0 ~ :-
HCFA's contractors. ~::OG
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The . :<. .::::
A ProVlder A8rees: .., I . >
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1. That it will be responsible for all Medicare claims submitted to HCF A by itself: its employl:s, o~
its agents.
EDI Enrollment Form
2. That it will not disclose any infonnation concerning a Medicare beneficiary to any other person or
organization, except HCF A and/or its contractors. without the express written permission of the
Medicare beneficiary or hislher parent or legal guardian, or where required for the care and treatment of
a beneficiary who is unable to provide written consent, or to bill insurance primary or supplementary to
Medicare, or as required by State or F ederallaw.
3. That it will submit claims only on behalf of those Medicare beneficiaries who have given their
written authorization to do so, and to certify that required beneficiary signatures, or legally authorized
signatures on behalf of beneficiaries, are on file.
4. That it will ensure that every electronic entry can be readily associated and identified with an
original source document Each source document must reflect the following infonnation.
· Beneficiary's name,
. Beneficiary's health insurance claim number,
. Date (s) of service,
. Diagnosis/nature of illness, and
. Procedure/service perfonned.
5. That the Secretary of Health and Human Services or hislher designee and/or the contractor has the
right to audit and confinn infonnation submitted by the provider and shall have access to all original
source documents and medical records related to the provider's submissions. including the
beneficiary's authorization and signature. All incorrect payments that are discovered as a result of such
an audit shall be adjusted according to the applicable provisions of the Social Security Act, Federal
Regulations, and HCF A guidelines.
6. That it will ensure that all claims for Medicare primary payment have been developed for other
insurance involvement and that Medicare is the primary payer.
7. That it will submit claims that are accurate, complete, and truthful.
8. That it will retain all original source documentation and medical records pertaining to any such
particular Medicare claim for a period of at least 6 years, 3 months after the bill is paid.
9. That it will affix the HCF A-assigned Wlique identifier number of the provider on each claim
electronically transmitted to the contractor.
10. That the HCF A-assigned Wlique identifier number constitutes the provider's legal electronic
signature and constitutes an assurance by the provider that services were perfonned as billed.
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11. That it will use sufficient security procedures to ensure that all transmissions of documents are
authorized and protect all beneficiary-specific data from improper access.
12. That it will acknowledge that all claims will be paid from Federal funds, that the submission of
such claims is a claim for payment under the Medicare program, and that anyone who misrepresents or
falsifies or causes to be misrepresented or falsified any record or other information relating to that
claim that is required pursuant to this Agreement may, upon conviction, be subject to a fine and/or
imprisonment lD'lder applicable F ederallaw.
13. That it will establish and maintain procedures and controls so that information concerning
Medicare beneficiaries, or any information obtained from HCF A or its contractor, shall not be used by
agents, officers., or employees of the billing service c-,,<cept as provided by the contractor (in accordance
with Sll06(a) of the Act). .
14. That it will research and correct claim discrepancies.
15. That it will notify the contractor or the RCF A within 2 business clays if any transmitted c1ata are
received in an unintelligible or garbled form.
B. The Health Care Financin2 Administration will:
1. Transmit to the provider an acknowledgment of claim receipt.
., AffL"< the intermediary/carrier number, as its electronic signature, on each remittance advice sent to
the provider.
3. Ensure that payments to providers are timely in accordance with RCF A's policies.
4. Ensure that no contractor may require the provider to purchase any or all electronic services from
the contractor or from any subsidiary of the contractor or from any company for which the contractor
has an interest The contractor will make alternative means available to any electronic biller to oetain
such services.
5. Ensure that aU Medicare electronic billers have equal access to any services that RCF A requires
Medicare contractors to make available to providers or their billing services regardless of the electronic
billing technique or service they choose. Equal access will be granted to any services the contractor
sells directly, indirectly, or by arrangement.
6. Notify the provider within 2 business days if any transmitted data are received in an unintelligible
or garbled fonn.
NOTICE:
F ederallaw shaH govern both the interpretation of this document and the appropriate jurisdiction and venue for
appealing any final decision made by HCF A under this document.
This document shall become effective when signed by the provider. The responsibilities and obligations contained in
this document will remain in effect as long as Medicare claims are submitted to RCF A or the contractor. Either party
may terminate this arrangement by giving the other party (30) days written notice of its intent to terminate. In the
event that the notice is mailed, the written notice of termination shall be deemed to have been given upon the date of
mailing, as established by the postmark or other appropriate evidence of transmittal.
20f3
Wednesday 06 of Sep 2000, BCBSFL_JaCKSonVille ->Billing/lns Recovery Page 5 of 6
C. Signature:
I am authorized to sign this document on behalf of the indicated party and I have read and agreed to the foregoing provisions and
acknowledge same by signing below:
Provider's Name
Monroe County Emergency Medical Services
Title
Address
490 63rd Street, Suite 140
City/State/Zip
Title
Marathon, FL 33050
c..)? L f.~ 1 c:-J; L P~(h
Mayor
/0-/8... 00
By
Date
========================================================----==:==============================
PLEASE PROVIDE THE FOLLOWING MEDICARE INFORMATION
Telephone Number:
N Do &..<0
Po..\J' \= ro..(\ 'l...~\o.~
3oS- C14S- ll~O
~Billing Service Name of Company
Ai \10... (\ Co ed 00. -k ~ r (!) C-e.. s.s\ ('\ (."\
Sender Number:
o Clearinghouse Name of Company
Contact Person:
Type of Claim: 0 Medicare Part A 4 digit Provider Number: 10
)( Medicare Part B
PhysicianlSupplierlP A Group
Provider Number:
Mailing Address:
Medicare EDI
PO Box 44071 -7C
Jacksonville, FL 32231-4071
Attention:
Physical Address:
Medicare ED!
. KOLHAGE, aERK
;~o.J.....O C. .Lf(v)!~
DEPUTY CLERK
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This form must be completed by any applicant who will be using a billing agent
to submit claims for reimbursement by Florida Medicaid.
Please read Notice to Providers and Billio2 A2tnts on the back of this na2e.
1\./\ (l :ttMS 1\~\I~~C.E.h ~~\+- ?~CL~S\~C6,. ':tN(.
r. ,"'( _ 0 (\ fa e.. uotJ C'\ authorize '\ C\o~ \10 C - 0 0
(Provider aam&IpnMdcr 1IIIIIlba') (Bi1Iiac .pi Bi1Iiai .... provider 1IIIIIIbcr)
r- ~d.(b \-J\)J \\05 So-\- ~ \ . t--\l~"'\. ,\=L 331~'\ ~o5-<\4S-J.2..80
'0 ~:; i~ '," (~) . (Cily,l&IIc,zip) (Tolcpboad)
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:c ~~~t claims to and follow up with Medicaid and/or the Medicaid Fiscal Agen~' on my behalf.
a.. ~stand that all payments and payment infonnation are in my name and that this agreement
,r-;- dO~ aibt exempt me from responsibility for claims filed on my behalf or from established claim
::- ~~licies. I further understand that the billing agent must be held to the same requirements of
~ ~~lintialhy and access to records that I am, as reflected in my agreement with Medicaid. I will
g iiHm@ately notify the Medicaid fiscal agent of any change in this authorization.
-''V\ 0 (\ (' () e.. L f) U (\ ..h , EM S /h .. Y. r / G ~'...i ". ,.." 0. '1
Provider Name ~ Title' I
, (PUW~rmLEOIBLY) ,
1';rB::;~Cj;:,,,~~ Dale 16-, ~.OO
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If this form is being completed ~ you have been notified of your Florida Medicaid provider
number(s)t please supply the provider number(s) you have been assigned to your practice or
facility. Otherwise, you may leave this section blank.
Florida Medicaid Provider Numbers ~
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23
eturn this completed agreement with your application or, after provider number is
i&ned, lend it directly to:
Medicaid FilcaI Alent
Provider EDroDmeat
GE, OERK P. O. Box 7070
8', '-~~ l c .Lau~ ~alIabUIee, FL 3131....7070
DEPUTY ClEA~ '
ARCA Form 2200.0003 (November 1998)
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The fo~owing requirements apply to all billing agents:
. You must.be enrolled in the Medicaid program as a billing agent with an active provider
number to bill claims on behalf of an enrolled Medicaid provider.
. Claims must be paid in the name of the provider or provider group that renders the services,
not in the name of the billing agent.
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. Payment for billing services must be made based 'upon an administrative fee per claim. Federal
regulation (42 CPR 447.10, Subpart A) prohibits billing agents from charging fot their
services based upon a percentage of the total doUar value of claims billed.
. If a claim is rejected as inaccurately filed, it cannot be resubmitted unless there has been a
change made to the claim fonn or electronic submission itself
.
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ARCA Fonn 2200-0003 (November 1998)
APPLICATION Page 18 .
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