10/18/2006 Agreement
DANNY L. KOLHAGE
CLERK OF THE CIRCUIT COURT
DATE:
October 31, 2006
TO:
Deb Barsell, Director
Community Services
ATTN:
Sandy Molina, Assistant
to the Division Director
Pamela G. Hanc~
Deputy Clerk 0
FROM:
At the October 18, 2006, Board of County Commissioner's meeting the Board granted
approval and authorized execution of the Non-Institutional Medicaid Provider Agreement for
Monroe County to re-enroll in a Provider Agreement with the Florida Medicaid Program.
Enclosed are two duplicate originals of the above-mentioned for your handling. Should
you have any questions please do not hesitate to contact this office.
cc: County Attorney
Finance
File/
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FlORIa... AGENCY fOR HfAl.1H CARE K)MINISTRATIC'lN
NON-INSTITUTIONAL
MEDICAID PROVIDER AGREEMENT
The Provider agrees to participate in the Florida Medicaid program under the following terms and conditions:
(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
otigin, 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 service~
or goods must have been actually provided to eligible Medicaid recipients by the provider prior to submitting the
claim.
(3) Cnmplianc" The provider agrees to comply with local, state, and federal laws, as well as rules, regulations, ani
statements of policy applicable to the Medicaid program, inclUding the Medicaid Provider Handbooks issued by
AHCA.
(4) Term and signatures. 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 have been met, this agreement shall remain in effect for ten (10) years from the effective date of the
provider's eligibility unless otherwise terminated. This agreement shall be renewable only by mutual consent. The
provider understands and agrees that no AHCA signature is required to make this agreement valid and enforceable
(5) Provider ResDonsibilities. 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 being 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.
(e) Safeguard the use and disclosure of information pertaining to current or former Medicaid recipients as required
by law.
(d) Send, at the provider's expense, legible copies of all Medicaid-related information to authorized state and
federal employe"s, including their agents. The provider shall give state and federal employees, including their
agents, access to all Medicaid patient records and to other information that can not be separated from
Nedicaid-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.
(0 Within 90 days of receipt, refund any moneys received in error or in excess of the amount to which the provider
is entitled from the Medicaid program.
(g) To the extent allowed by in and accordance with section 768.28, F.S. (2001), and any successor legislation, be
liable for and 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 person believed to be a recipient.
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Non-Institutional MPA (Revised July 2006)
F!NPA20S;06
(h) Accept Medicaid payment as payment in full, and not bill or collect from the recipient or the recipient's
responsible. party any additional amount except, and only to the extent AHCA permits or requires, co-payments
coinsurance, or deductibles to be paid by the recipient for the services or goods provided. This includes situati'ons
in which the provider's Medicare coinsurance claims are denied in accordance with Medicaid's payment.
(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 Responsibilities. The agency shall:
(a) 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.
(h) 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 may be terminated without cause upon thirty (30) days written
notice by either party.
(8) Ownership. 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.
(9) Complete Information. All statements and information furnished by the prospective provider before si9ning the
provider agreement shall be true and complete. The filing of a materially incomplete, misleading or false
application will make the application and agreement voidable at the option of AHCA and is sufficient cause for
immediate termination of the provider from the Medicaid program and/or revocation of the provider number.
(10) Interpretation. This agreement shall not be construed against either party on the basis of this agreement
having been prepared by one of the parties.
(11) Governino Law. This agreement shall be governed by and construed in accordance with the laws of the State
of Florida.
(12) Amendment. This agreement, the application and other documents being executed and delivered pursuant
hereto constitute the full and entire agreement and understanding between the parties hereto with respect to the
subject matter hereof. No amendment shall be effective unless it is in writing and signed by each party.
(13) Severabilitv. If one or more of the provisions contained in this agreement or application shall be invalid, illegal
or unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be
affected or impaired.
(14) Aareement Retention. The parties agree that AHCA may only retain the signature page of this agreement, and
thet a copy of this standard provider agreement will be maintained by the Director of Medicaid, or his designee, and
may be reproduced as a duplicate original for any legal purpose and may also be entered into evidence as a
business record.
(15) Fundina. This contract is contingent upon the availability of funds.
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N on.!nstitutional MPA (Revised July 2006)
F8NPB208/06
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'TII.. parties concur that this agreement is a legal and binding document and is fully enforceable in a court of
competent jurisdiction. The signatories hereto represent and warrant that they have read the agreement,
understand it, and are authorized to execute it on behalf of their respective principals or co-owners. This
agreement becomes null and void upon transfer of assets; change of ownership; or upon discovery by ahca of the
submission of a materially incomplete, misleading or false provider application unless subsequently ratified or
approved by ahca.
All shareholders (with five percent or greater ownership interest), principals, partners and financial custodians are
required to sign this agreement or, a chief executive officer (CEO) or president of an organization may sign this
agreement in lieu of the above. Failure to sign the agreement will make this application, agreement and provider
number voidable by AHCA.
IN WITNESS WHEREOF, the undersigned have caused this agreement to be duly executed under the
penalties of perjury, swear or affirm that the foregoing is true and orrect,
Charles "Sonny" KcCoy
Kayor
(legibly print name of signatory)
Title
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(USE ADDITIONAL PAGES IF NECESSARY
Provider's Name:
MONROE COUNTY
DBA Name:
Tax Identification Number:
59-6000749
National Provider Identifier:
Florida Medicaid
Identification Number:
(F10T new applicants this block will
be completed by the fiscal agent.)
676448700
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MPA Revised April 2003
F8NPCl 06/12/03
10/18/06
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