2. 11/21/2000 Agreement
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BRANCH OFFICE
3117 OVERSEAS IDGHWAY
MARATIiON, FLORIDA 33OSO
TEL. (305) 289-6027
FAX (305) 289-1745
CLERK OF 1HE CIRCUIT COURT
MONROE COUNTY
500 WInTEHEAD STREET
KEY WEST, FLORIDA 33040
lEL. (305) 292-3550
FAX (305) 295-3660
BRANCH OFFICE
88820 OVERSEAS IDGHWAY
PLANTATION KEY, FLORIDA 33070
lEL. (305) 852-7145
FAX (305) 852-7146
MEMORANDUM
DATE:
December 5,2000
TO:
Louis Latorre, Director
Social Services Division
Pamela G. Hancor~
Deputy Clerk 0
FROM:
At the November 21, 2000, Board of County Commissioners meeting the Board granted
approval and authorized execution of a Institutional Medicaid Provider Agreement between
Monroe County and State of Florida, Agency for Health Care Administration, to participate in the
Florida Medicaid Program for Assistive Care Services for residents of Bay shore Manor.
Enclosed please find a duplicate original for your handling. Should you have any questions
please do not hesitate to contact this office. ·
Cc: County Administrator w/o document
County Attorney
Finance
File ,/
(1) Discrimination. The Parties agree that the Agency for Health Care Administration (AHCA) may make payments for
medical assistance and related services rendered to Medicaid recipients only to a person or entity who has a provider
agreement in effect with AHCA; who is performing services or supplying goods in accordance with federal, state, and
local law; and who agrees that no person shall, on the grounds of sex, handicap, race, color, national origin, other
insurance, or for any other reason, be subjected to discrimination under any program or activity for which the provider
receives payment from AHCA.
(2) Quality of Service. The provider agrees that services or goods billed to the Medicaid program must be medically
necessary, of a quality comparable to those furnished by the provider's peers, and within the parameters permitted by the
provider's license or certification. The provider further agrees to bill only for the services performed within the specialty
or specialties designated in the provider application on file with AHCA. The provider must deliver the services or goods
to eligible Medicaid recipients to receive payment from AHCA.
(3) Comoliance. The provider agrees that the submission for payment of claims for services will constitute a certification
that the services were provided in accordance with local, state and federal laws, as well as rules and regulations
applicable to the Medicaid program, including the Medicaid Provider Handbooks issued by AHCA.
(4) Term and sianatures. The parties agree that this is a voluntary agreement between AHCA and the provider, in which
the provider agrees to furnish services or goods to Medicaid recipients. Provided that all requirements for enrollment are
met and remain in effect, this agreement shall remain in' effect for five (5) years from the effective date of the provider'S
eligibility which is written in the office area below unless otherwise terminated. This agreement is renewable only by
mutual consent. The provider understands and agrees that no AHCA signature is required to make this agreement valid
and enforceable. This agreement shall be accepted and entered into by AHCA upon the assignment of a provider
number and effective date as provided for herein.
(5) Provider Resoonsibilities. The Medicaid provider shall:
(a) Possess at the time of the signing of the provider agreement, and maintain in good standing throughout the period of
the agreement's effectiveness, a valid professional, occupational, facility or other license appropriate to the services or .
goods provided, as required by law.
(b) Keep, maintain, and make available in a systematic and orderly manner all medical and Medicaid-related records as
AHCA requires for a period of at least five (5) years.
(c) Safeguard the use and disclosure of information pertaining to current or former Medicaid recipients as required by
law.
(d) Send, upon request or as required by applicable handbooks and at the provider's expense, legible copies of all
Medicaid-related information to authorized state and federal employees, including their agents. The provider s.hall give
state and federal employees, including their agents, access to all Medicaid patient records and to other information that is
inseparable from Medicaid-related records.
(e) Bill other insurers and third parties, including the Medicare program, before billing the Medicaid program, if the
recipient is eligible for payment for health care or related services from another insurer or person.
(f) Refund within 90 days of receipt any moneys received in error or in excess of the amount to which the provider is
entitled from the Medicaid program.
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(g) Remain liable for, indemnify, defend, and hold AHCA harmless from all claims, suits, judgments, or damages,
including court costs and attorney's fees, arising out of the negligence or omissions of the provider in the course of
providing services to a recipient or a potential recipient.
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(h) Accept Medicaid paY)Jlftllt as payment iri.full, and not bill or collect from the recipient or the recipient's responsible
party any additional amount except to the extent AHCA permits or requires, co-payments, coinsurance, or deductibles
will recipients' pay for the services or goods provided. This includes situations in which the provider's Medicare
coinsurance claims are denied. in. accordance with Medicaid's payment.
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(i) Agrees to submit claims to AHCA electronically and to abide by the terms of the Electronic Claims Submission
Agreement. .
,
(j) Agrees to receive payment from AHCA by Electronic Funds Transfer (EFT). In the event that AHCA erroneously
deposits funds to the provider's account, then the provider agrees that AHCA may withdraw the funds from the account.
(6) AHCA Resoonsibilities. AHCA:
(a) Is required to make timely payment at the established rate for services or goods furnished to a recipient by the
provider upon receipt of a properly completed claim. .
(b) Will not seek repayment from the provider in any instance in which the Medicaid overpayment is attributable solely to
error in the state's determination of eligibility of a recipient.
(7) Termination For Convenience. This agreement is terminable upon thirty (30) days written notice with or without
cause by either party.
(8) Ownershio. The provider agrees to give AHCA sixty (60) days written notice before making any change in ownership
of the entity named in the provider agreement as the provider. The provider is required to maintain and make available
to AHCA Medicaid-related records that relate to the sale or transfer of the business interest, practice, or facility in the
same manner as though the sale or transaction had not taken place, unless the provider enters into an agreement with
the purchaser of the business interest, practice, or facility to fulfill this requirement. Nursing facilities have the option to
assign this agreement to the new provider as a result of sale, lease, or any other change. in operational ownership subject
to all terms and conditions under which the agreement was originally issued. In the event of a change in Hospital
ownership, the new provider agrees to assume all liabilities due from previous providers to the agency, regardless of
when the liabilities are identified, in order to participate in the Medicaid program.
(9) Comolete Information. The provider is required to furnish true and complete statements and information to AHCA
before signing the provider agreement. The provider is obligated to inform AHCA in writing of any change in the
statements and information prior to the change. The filing of a materially incomplete, misleading or false application will
make the application and agreement voidable at the AHCA's option and is sufficient cause immediate termination of the
provider from the Medicaid program ancllor revocation of the provider's number.
(10) Interoretation. When interpreting thi~agreement, it shall be neither construed against either party nor considered
which party prepared the agreement. . .
(11) Governing law. The parties consent to governance by and interpretation of their agreement in accordance with the
State of Florida's laws.
(12) Amendment. This agreement, application and supporting documents constitute the full and entire agreement and
understanding belYleen the parties with respect to their relationship. No amendment is effective unless it is in writing and
signed by each party.
(13) Severability. If one or more of the provisions contained in this agreement or application are declared invalid, then
the. other provisions remain valid.
(14) Aareement Retention. The parties agree that AHCA may only retain the signature page of this agreement, and that
a copy of this standard provider agreement is maintained by the Director of Medicaid, or his designee, and reproduced as
a duplicate original for any purpose and usable as evidence in any legal proceeding.
(15) Funding. This contract is contingent upon the availability of funds.
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(16) Assianabilitv, The parties agree that neither may assign their rights under this agreement without the express
written consent of the other.
THE SIGNATORIES REPRESENT THAT THEY HAVE READ THE AGREEMENT, UNDERSTAND IT, AND ARE
AUTHORIZED TO EXECUTE IT ON BEHALF OF THEIR RESPECTIVE PRINCIPALS.
FOR OFFICE USE ONLY
The Provider entity name is:
The facility's d/b/a name is:
The provider number is:
The effective date of this agreement is:
The termination date is:
dates and numbers are added u
IN WITNESS WHEREO . the undersigned representative of the above executed this agreement under the penalty of
perjury and now affir hat the foregoing is ue and correct.
II/L'/CO
Date
Signature and T"
George Neugent, Mayor
(You must legibly print or type the above signature and title.)
l)Q-n00074q
{You must legibly print or type your Federal Employer Identification Number (FEIN).}
NE A HUTTON
"'T~.__ IOf ,/(ftl
l..f1DA ~_...-..""~1 'lnnn
This form must be completed by individual Medicaid provider applicants,
provider groups, or businesses who will be billing Medicaid directly for
services. Turn pag:e over for instructions on how to properlv fill out this form.
. I (we) hereby authorize the Fiscal Agent for'the State of Florida, Agency for Heahh Care
Administration to make deposits to my (our) checking or savings account and the depository bank:
indicated below, hereinafter called Depository, to credit the same to such account.
First State Bank of .
DEPOSITORY NAME the Florida Keys BRANCH 1201 S:imJnton St.
CITY Key West
STATE FL
ZIP CODE 33040
. BANK TELEPHONE # 305/293-6828
BANK TRANSIT/ABA NUMBER 067000438
BANK ACCOUNT NUMBER 0100210041
EFFECTIVE DATE
This authority is to remain in effect as long as 1.( we) receive Medicaid payments. I understand
that this electronic funds transfer deposit/payment will be from federal and state funds and that
any falsification or concealment or a material fact involving the deposit may be prosecuted under
federal and state laws.
Monroe County Board of County Conmissioners
Depository Account
NAME ON BANK ACCOUNT
PROVIDER NAME & TELEPHONE # Rayr;;hore M~or
305/294-4966
MEDICAID PROVIDER NUMBER
LIST ALL INDIVIDUALs AUTHOlUZED TO SIGN ON TIllS ACCOUNT:
Danny Kolhage, C1erlc of Court
Geo~e NP11epnr. M.qynr
DATE ,\ - ~ \- 00 SlONE
(The person( s) signing this form must
NOl"'
ARCA Form 2200-0003 (October, 2000 temp ALF)
APPLICA nON Page 6