4. 07/18/2007 Agreement
DANNY L. KOLHAGE
CLERK OF THE CIRCUIT COURT
DATE:
August 7, 2007
TO:
Deb Barsel/, Director
Community Services
ATTN:
Sandy Molina, Assistant
to the Division Director
FROM:
Pamela G. Hanc~
Deputy Clerk CY
At the July 18, 2007, Board of County Commissioner's meeting the Board granted
approval and authorized execution of the Institutional Medicaid Provider Agreement between
Monroe County and the Agency for Health Care Administration for Monroe County Bayshore
Manor to re-enroll in a Provider Agreement for participation in the Title XIX Institutional
Florida Medicaid Program.
Enclosed is a duplicate original of the above-mentioned for your handling. Should you
have any questions please do not hesitate to contact this office.
cc: County Attorney
Finanye
File.l
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INSTITUTIONAL
MEDICAID PROVIDER AGREEMENT
~
FlORlDAPGENCY FOR HEAlTH CARE AONJNISTRATlON
The Provider agrees to participate in the Florida Medicaid program under the following temns 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 perfomning 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) Qualitv 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 to comply with local, state, and federal laws, as well as rules, regulations, and
statements of policy applicable to the Medicaid program, including the Medicaid Provider Handbooks issued by AHCA.
(4) Term and sionatures. 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 three (3) years from the effective date of the provider's
eligibility 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 shall 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 any moneys received from the Medicaid program in error or in excess of the amount to which the provider is
entitled within 90 days of receipt.
MPA Institutional Revised February 2007
10f3
(g) Be liable for and indemnify, defend, and hold AHCA harmless from all claims, suits, judgments, or damages, iQcluding
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 to the extent allowed by in and accordance with section
768,28, F.S. (2001), and any successor legislation.
(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 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.
(i) Submit claims to AHCA electronically and. to abide by the terms of the Electronic Claims Submission Agreement.
U> 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.
(k) Comply with all of the requirements of Section 6032 (Employee Education About False Claims Recovery) of the Deficit
Reduction Act of 2005, if the provider receives or earns five million dollars or greater annually under the State plan.
(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 wiih 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 compiete 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 and/or revocation of the provider's number.
(10) 'Interoretation. When interpreting this agreement, it shall be neither construed against either party nor considered
which party prepared the agreement.
(11) Governino 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 between the parties with respect to their relationship. No amendment is 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 are declared invalid, then the
other provisions remain valid.
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20f3
(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) Fundina. This contract is contingent upon the availability of funds.
(16) Assianabilitv, The parties agree that neither may assign their rights under this agreement without
the express written consent of the other.
THE PARTIES CONCUR THAT THIS AGREEMENT IS A LEGAL AND BINDING DOCUMENT AND IS
FULLY ENFORCEABLE IN A COURT OF COMPETENT JURISDICTION.
THE SIGNATORY REPRESENTS THAT HE OR SHE HAS READ THE AGREEMENT, UNDERSTANDS
IT, AND IS AUTHORIZED TO EXECUTE IT ON BEHALF OF HIS OR HER RESPECTIVE PRINCIPALS.
IN WITNESS WHEREOF, the undersigned representative of the above executed this agreement under
the penalty of perjury and now affirms that the foregoing is true and correct.
MONROE COUNTY ATTORNEY
APP~f T' F~RM:
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IA L ~ A1L-".!LL
!,SSISTANT COUN:'Y Af'toR.NEY
Date
~~t,tkJ)
Mario DiGennaro
(legibly print name of signatory)
Mayor
Title
18, 2007
Please Complete The Following Information:
Provider's Name:
Bayshore Manor
DBA Name:
Tax Identification Number: 53 - &000 "I If 'J
Florida Medicaid Identification Number: 140159900
(For new applicants the Medicaid ID will be supplied by the fiscal agent upon approval of the
application.)
National Provider Identifier: (Required)
Taxonomy Code: (Optional)
Effective Date of This Agreement:
Termination Date of This Agreement:
9/1/2007
8/31/2010
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