01/20/2010 Agreement
DANNY L. KOLHAGE
CLERK OF THE CIRCUIT COURT
DATE:
January 26, 2010
TO:
Sheryl Graham, Director
Social Services
Pamela G. Ha~c.
FROM:
At the January 20,2010, Board of County Commissioner's meeting the Board granted
approval and authorized execution of the following:
Agreement between the Monroe County Community Transportation
Coordinator/Guidance Clinic of the Middle Key and Monroe County Board of County
Commissioners for Contract period of 01/01/201 0 through 12/31/2010.
Contract between Monroe County and the Community Transportation
Coordinator/Guidance Clinic of the Middle Keys for a Contract period of 01/01/2010 through
12/31/2010.
Enclosed are two duplicate originals of each of the above-mentioned for your handling.
Should you have any questions, please do not hesitate to contact our office.
cc: County Attorney
Finance
File
NON-EMERGENCY TRANSPORTATION (NET) PROGRAM
SUBCONTRACTED TRANSPORTATION PROVIDER AGREEMENT
BY THIS AGREEMENT, made and entered into this --1-day of January , 2010, by and between the
Guidance/Care Center, Inc., hereinafter called "CTC" and Monroe County Board Of County
Commissioners, hereinafter called "Provider":
1. SERVICES AND PERFORMANCE
A. In connection with the delivery of Medicaid Non-Emergency Transportation Services, the
CTC does hereby retain the PROVIDER to furnish certain services, information, and
items as described in Exhibits A and B and Attachments, attached hereto and made a
part hereof.
B. Before making any additions or deletions to the work described in this Agreement, and
before undertaking any changes or revisions to such work, the parties shall negotiate
any necessary cost changes and shall enter into an Amendment covering such work and
compensation. Reference herein to this Agreement shall include any amendment(s).
C. All plans, maps, computer files, and/or reports prepared or obtained under this
Agreement, as well as all data collected, together with summaries and charts derived
there from, shall become the property of the Commission for Transportation
Disadvantaged, (CTD), without restriction or limitation on their use and Shall be made
available upon request, to the CTD at any time during the performance of such services
and/or upon completion or termination of this Agreement. Upon delivery to the CTD of
said document(s), the CTD shall become the custodian thereof in accordance with
Chapter 119, Florida Statutes. The PROVIDER shall not copyright any material and
products or patent any invention developed under this Agreement. The CTC shall have
the right to visit the site for inspection of the work and the products of the PROVIDER at
any time.
The CTC shall have the right to use, disclose, or duplicate all information and data
developed, derived, documented, or furnished by the PROVIDER resulting from this
Contract. Nothing herein shall entitle the CTC to disclose to third parties data or
information that is otherwise protected from disclosure by State or federal law.
D. The PROVIDER agrees to provide reports in a format acceptable to the CTC and at
intervals established by the CTC. The CTC shall be entitled at all times to be advised, at
its request, as to the status of work being done by the PROVIDER and of the details
thereof. Coordination shall be maintained by the PROVIDER with representatives of the
CTC, or of other agencies interested in the project on behalf of the CTC. Either party to
the Agreement may request and be granted a conference.
E. All services shall be performed by the PROVIDER to the satisfaction of the Director who
shall decide all questions, difficulties, and disputes of any nature whatsoever that may
arise under or by reason of this Agreement, the prosecution and fulfillment of the
services hereunder and the character, quality, amount of value thereof; and the decision
upon all claims, questions, and disputes shall be final and binding upon the parties
hereto. Adjustments of compensation and contract time because of any major changes
in the work that may become necessary or desirable as the work progresses shall be
subject to mutual agreement of the parties, and amendment(s) shall be entered into by
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the parties in accordance herewith.
Reference herein to the Director shall mean the Executive Director of the CTD for the
Transportation Disadvantaged.
2.
TERM
A.
INmAL TERM. This Agreement shall begin on January 1, 2010 and shall remain in full
force and effect through completion of all services required on December 31, 2010.
B. RENEWALS: This Agreement may be renewed for a period that may not exceed three
(3) years or the term of the original Agreement, whichever period is longer. Renewals
shall be contingent upon satisfactory performance evaluations by the CTC and subject to
the availability of funds. Any renewal or extension shall be in writing and executed by
both parties, and shall be subject to the same terms and conditions set forth in this
Agreement.
C. EXTENSIONS. In the event that circumstances arise which make performance by the
PROVIDER impracticable or impossible within the time allowed or which prevent a new
Agreement from being executed, the CTC, in its discretion, may grant an extension of
this Agreement. Extension of this Agreement shall be in writing for a period not to
exceed six (6) months and shall be subject to the same terms and conditions set forth in
this Agreement; provided the CTC may, in its discretion, grant a proportional increase in
the total dollar amount based on the method and rate established herein. There shall
be only one extension of this Agreement unless the failure to meet the criteria set forth
in this Agreement for completion of this Agreement is due to events beyond the control
of the PROVIDER.
3. COMPENSATION AND PAYMENT
A. Payment shall not be made until funds from Agency for Health Care Administration have
been received and deposited by the CTC. Payment shall be made only after receipt and
approval of goods and services unless advanced payments are authorized by the Chief
Financial Officer of the State of Florida under Section 215.422 (14), Florida Statutes.
B. This Agreement involves units of deliverables and they must be received and accepted in
writing by the CTO's Contract Manager prior to payments.
C. The CTD has eleven (11) working days to inspect and approve the deliverables, unless
otherwise specified herein. The CTD has 20 days to deliver a request for payment
(voucher) to the Department of Financial Services. The 20 days are measured from the
latter of the date the invoice is received or the goods or services are received, inspected
and approved.
D. If a payment is not available within 40 days, a separate interest penalty pursuant to
Section 215.422(3)(b), F.S., shall be due and payable, in addition to the invoice amount,
to the PROVIDER. Invoices which have to be returned to a PROVIDER because of
PROVIDER preparation errors shall result in a delay in the payment. The invoice
payment requirements do not start until payment for Agency for Health Care
Administration has been received by the CTD and until a properly completed invoice is
provided to the CTD.
E. The State of Florida, through the Department of Management Services, has instituted
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MyFloridaMarketPlace, a statewide eProcurement system. All PROVIDERs must be
registered in the My Florida Market Place. Pursuant to Section 287.057(23), Florida
Statutes, all payments shall be assessed a transaction fee of one percent (10/o),which
shall be paid to the State. Services provided under this Contract are exempt pursuant to
Rule 60A-1.032(h), Florida Administrative Code.
F. A Vendor Ombudsman has been established within the Department of Financial
Services. The duties of this individual include acting as an advocate for vendors who
may be experiencing problems in obtaining timely payment(s) from the CTD. The
Vendor Ombudsman may be contacted at (850) 410-9724 or by calling the Consumer
Hotline, 1-800-848-3792.
G. Records of costs incurred under terms of this Agreement shall be maintained and made
available upon request to the erc at all times during the period of this Agreement and
for five (5). years after final payment for the work pursuant to this Agreement is made.
Copies of these documents and records shall be furnished to the erc upon request.
Records of costs incurred shall include the PROVIDER's general accounting records and
the project records, together with supporting documents and records, of the PROVIDER
and all subcontractors performing work, as provided in Exhibit A, Scope of Work and all
other records of the PROVIDER and subcontractors considered necessary by the ere for
a proper audit of project costs.
H. The erc, during any fiscal year, shall not expend money, incur any liability, or enter into
any contract which, by its terms, involves the expenditure of money in excess of the
amounts budgeted as available for expenditure during such fiscal year. Any contract,
verbal or written, made in violation of this subsection is null and void, and no money
may be paid on such contract. The erc shall require a statement from the CTD that
funds are available prior to entering into any such contract or other binding commitment
of funds. Nothing herein contained shall prevent the making of contracts for periods
exceeding one year, but any contract so made shall be executory only for the value of
the services to be rendered or agreed to be paid for in succeeding fiscal years.
Accordingly, the CTC's performance and obligation to pay under this Agreement is
contingent upon an annual appropriation by the Legislature.
I. For the satisfactory performance of the services and the submittal of Encounter Data as
outlined in Exhibit A, Scope of Services, the PROVIDER shall be paid up to a maximum
amount of $ 70.000 .
The PROVIDER shall not provide services that exceed the limiting amount(s) without an
approved amendment from the erc. The total amount of this contract is expected to be
funded by multiple appropriations and the State of Florida's performance and obligation
to pay under this contract is contingent upon annual appropriations by the Legislature.
The PROVIDER shall submit invoices in a format acceptable to the erc. The PROVIDER
will be paid, after the erc has received payment from Agency for Health Care
Administration. The PROVIDER shall request payment through submission of a properly
completed invoice to the erc in accordance with Exhibit S, Method of Compensation.
J. The PROVIDER must submit the final invoice for payment to the ere no more than
thirty (30) days after the Agreement ends or is terminated. If the PROVIDER fails to do
so, all right to payment is forfeited and the CTC will not honor any requests submitted
after the aforesaid time period. Any payment due under the terms of this Agreement
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may be withheld until all reports due from the PROVIDER and necessary adjustments
thereto have been approved by the erc.
K. The State of Florida's (erC's) performance and obligation to pay under this Agreement is
contingent upon an annual appropriation by the Legislature and nothing herein shall be
construed to violate the provisions of Section 339.135(6)(a), Florida Statutes, which
provides the erc, during any fiscal year, shall not expend money, incur any liability, or
enter into any contract which, by its terms, involves the expenditure of money in excess
of the amounts budgeted as available for expenditure during such fiscal year. Any
contract, verbal or written, made in violation is null and void and no money may be paid
on such contract.
4. INDEMNITY, PAYMENT FOR CLAIMS AND INSURANCE
A. INDEMNITY: The Provider, as a political sub-division of the State of Florida, as defined
in Section 768.28, Florida Statutes, agrees to be fully responsible to the limits set forth
in such statute for its own negligent acts or omissions, or intentional tortuous acts,
which result in claims or suits against either the Provider or erc, and agrees to be liable
to the statutory limits for any damages proximately caused by said acts or omissions, or
intentional tortuous acts.
Nothing contained in this Section shall be construed to be a waiver by either party of
any protections under sovereign immunity, Section 768.28 Florida Statutes, or any other
similar provision of law. Nothing contained herein shall be construed to be a consent by
either party to be sued by third parties in any matter arising out of this or any other
Agreement.
B. PAYMENT FOR CLAIMS: The erc guaranties the payment of all just claims against the
PROVIDER or any subcontractor, in connection with the Agreement. The erc's final
acceptance and payment does not release the PROVIDER's responsibilities until all such
claims are paid or released.
C. LIABILITY INSURANCE: The PROVIDER shall carry and keep in force during the period
of this Agreement a general liability insurance policy or policies with a company or
companies authorized to do business in Florida, affording public liability insurance in
accordance with Rule Chapter 41-2.006, Florida Administrative Code. If the PROVIDER is
a political subdivision of the State of Florida and is self-insured in accordance with the
terms and provisions of Section 768.28, Florida Statutes regarding waiver of sovereign
immunity in tort actions, the PROVIDER shall provide to the erc a Certificate of Self-
Insurance upon execution of this Agreement. Any lapse in coverage shall be reported in
writing to the erc.
D. WORKERS' COMPENSATION. The PROVIDER shall carry and keep in force Workers'
Compensation Insurance as required for the State of Florida under the Worker's
Compensation Law during the term of this Agreement.
E. CERTIFICATION. With respect to any insurance policy required pursuant to this
Agreement, all such policies shall be issued by companies licensed to do business in the
State.of Florida. The PROVID~R shall provide to the erc certificates showing the
required coverage to be in effect and showing the erc to be an additional certificate
holder. Such policies shall provide that the insurance is not cancelable except upon
thirty (30) days prior written notice to the erc.
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5. COMPUANCE WITH LAWS AND REGULATIONS
A. The PROVIDER agrees to comply with all applicable federal and State laws, rules and
regulations including but not limited to: Title 42 CFR Chapter IV, Subchapter C; Title 45
CFR Part 74, General Grants Administration Requirements; Chapters 409 and 641, F.S.;
Part I of Chapter 427, F.S., Rule 41-2, F.A.C., the Electronics Accessibility Act, all
applicable standards, orders, or regulations issued pursuant to the Clean Air Act of 1970
as amended (42 USC 1857, et seq.); Title VI of the Civil Rights Act of 1964 (42 USC
2000d) in regard to persons served; Title IX of the education amendments of 1972
(regarding education programs and activities); 42 CFR 431, Subpart F; Section
409.907(3)(d), F.S., and Rule 59G 8.100 (24)(b), F.A.C. in regard to the contractor
safeguarding information about Medicaid Beneficiaries; Title VII of the Civil Rights Act of
1964 (42 USC 2000e) in regard to employees or applicants for.employment; Rule 59G-
8.100, F.A.C.; Section 504 of the Rehabilitation Act of 1973, as amended, 29 USC 794
(which prohibits discrimination on the basis of handicap in programs and activities
receiving or benefiting from federal financial assistance); the Age Discrimination Act of
1975, as amended, 42 USC 6101 et. seq. (which prohibits discrimination on the basis of
age in programs or activities receiving or benefiting from federal financial assistance);
the Omnibus Budget Reconciliation Act of 1981, P.L. 97-35, which prohibits
discrimination on the basis of sex and religion in programs and activities receiving or
benefiting from federal financial assistance; Medicare - Medicaid Fraud and Abuse Act of
1978; the federal Omnibus Budget Reconciliation Acts; Americans with Disabilities Act
(42 USC 12101, et seq.); the Newborns' and Mothers' Health Protection Act of 1996, the
Balanced Budget Act of 1997, and the Health Insurance Portability and Accountability
Act of 1996. The PROVIDER is subject to any changes in federal and state law, rules, or
regulations.
B. The PROVIDER shall allow public access to all documents, papers, letters, or other
material subject to the provisions of Chapter 119, Florida Statutes, and made or
received by the PROVIDER in conjunction with this Agreement. Failure by the PROVIDER
to grant such public access shall be grounds for immediate unilateral cancellation of this
Agreement by the CTC.
C. The PROVIDER agrees that it shall make no statements, press releases or publicity
releases concerning this Agreement or its subject matter or otherwise disclose or permit
to be disclosed any of the data or other information obtained or furnished in compliance
with this Agreement, or any particulars thereof, during the period of the Agreement,
without first notifying the CTDC's Contract Manager and securing prior written consent.
The PROVIDER also agrees that it shall not publish, copyright, or patent any of the data
developed under this Agreement, it being understood that such data or information are
works made for hire and the property of the CTC.
D. The PROVIDER shall comply with all federal, state, and local laws and ordinances
applicable to the work or payment for work thereof, and will not discriminate on the
grounds of race, color, religion, sex, national origin, age, or disability in the performance
of work under this Agreement.
E. If the PROVIDER is licensed by the Department of Business and Professional Regulation
to perform the services ~erein contracted, then Section 337.162, Florida Statutes,
applies as follows:
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1) If the CTC has knowledge or reason to believe that any person has violated the
provisions of the state professional licensing laws or rules, it shall submit a
complaint regarding the violations to the Department of Business and
Professional Regulation. The complaint shall be confidential.
2) Any person who is employed by the CTD and who is licensed by the Department
of Business and Professional Regulation and who, through the course of the
person's employment, has knowledge to believe that any person has violated the
provisions of state professional licensing laws or rules shall submit a complaint
regarding the violations to the Department of Business and Professional
Regulation. Failure to submit a complaint about the violations may be grounds
for disciplinary action pursuant to Chapter 455, Florida Statutes, and the state
licensing law applicable to that license. The complaint shall be confidential.
3) Any complaints submitted to the Department of Business and Professional
Regulation are confidential and exempt from Section 119.07(1), Florida Statutes,
pursuant to Chapter 455, Florida Statutes, and applicable state law.
F. A person or affiliate who has been placed on the convicted vendor list following a
conviction for a public entity crime may not submit a bid, proposal or reply on a contract
to provide any goods or services to a public entity, may not submit a bid, proposal or
reply on a contract with a public entity for the construction or repair of a public building
or public work, may not submit bids, proposals or replies on leases of real property to a
public entity, may not be awarded or perform work as a contractor, supplier,
subcontractor, or consultant under a contract with any public entity, and may not
transact business with any public entity in excess of the threshold amount provided in
Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from
the date of being placed on the convicted Vendor list.
G. An entity or affiliate who has been placed on the discriminatory Vendor list may not
submit a ,bid, proposal or reply on a contract to provide any goods or services to a public
entity, may not submit a bid, proposal or reply on a contract with a public entity for the
construction or repair of a public building or public work, may not submit bids, proposals
or replies on leases of real property to a public entity, may not be awarded or perform
work as a contractor, supplier, subcontractor, or consultant under a contract with a
public entity, and may not transact business with any public entity.
H. The CTC shall consider the employment by any PROVIDER of unauthorized aliens a
violation of Section 274A( e) of the Immigration and Nationality Act. If the PROVIDER
knowingly employs unauthorized aliens, such violation shall be cause for unilateral
cancellation of this Agreement.
I. Pursuant to Section 216.347, Florida Statutes, the PROVIDER may not expend any State
funds for the purpose of lobbying the Legislature, the judicial branch, or state agency.
This Contract contains federal funding, therefore, the PROVIDER shall, upon Contract
execution, complete the Certification regarding Lobbying Form, Attachment 2.
6. CONTRACT MANAGEMENT
A. The CTC shall be responsible for the management of this Contract. The CTD shall make
all statewide policy decision-making or Contract interpretation. In addition, the CTD shall
be responsible for the interpretation of all federal and State laws, rules and regulations
governing, or in any way affecting, this Contract. The CTC shall conduct the
management of this Contract in good faith, with the best interest of the State and the
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Medicaid Beneficiaries it serves being the prime consideration. The CTC shall consult
with the CTD and Agency for Health Care Administration to provide final interpretation
of general Medicaid policy. When interpretations are required, the PROVIDER shall
.submit written requests to the CTC.
B. The terms of this contract do not limit or waive the ability, authority or obligation of the
Office of Inspector General, the Bureau of Medicaid Program Integrity, its contractors, or
other duly constituted government units (State or federal) to audit or investigate
matters related to, or arising out of this Contract.
C. The parties shall amend the Contract only as follows:
1) The parties cannot amend or alter the terms of this Contract without a written
amendment.
2) Only a person authorized by the CTC and a person authorized by the PROVIDER
may amend or alter the terms of this Contract.
D. Contract Variation. If any provision of the Contract (including items incorporated by
reference) is declared or found to be illegal, unenforceable, or void, then both the erc
and the PROVIDER shall be relieved of aU obligations arising under such provisions. If
the remainder of the Contract is capable of performance, it shall not be affected by such
declaration or finding and shall be fully performed. In addition, if the laws or regulations
governing this Contract should be amended or judicially interpreted so as to render the
fulfillment of the Contract impossible or economically infeasible, both the CTC and the
PROVIDER shall be discharged from further obligations created under the terms of the
, Contract. However, such declaration or finding shall not affect any rights or obligations
of either party to the extent that such rights or obligations arise from acts performed or
events occurring prior to the effective date of such declaration or finding.
E. Representation of Entire Contract. This Contract with exhibits and numbered
attachments represents the entire agreement between the PROVIDER and the CTC with
respect to the subject matter in it and supersedes all other contracts between the
parties when the duly authorized representatives of the CTC and the PROVIDER signed
the Contract. Correspondence and memoranda of understanding do not constitute part
of this Contract. In the event of a conflict of language between the Contract and the
exhibits and attachments, the provisions of the Contract shall govern. However, the
CTC reserves the right to clarify any contractual relationship in writing with the
concurrence of the PROVIDER and such clarification shall govern. Pending final
determination of any dispute over a CTC decision, the PROVIDER shall proceed diligently
with the performance of the Contract.
7. ASSIGNMENT AND TRANSFER
The PROVIDER shall maintain an adequate and competent staff so as to enable the PROVIDER
to timely perform under this Agreement.
8. CONFUCT OF INTEREST
This Contract is subject to the provisions of Chapter 112, F .S. If applicable, the PROVIDER shall
disclose the name of any officer, director, or agent who is an employee of the State of Florida,
or any of its agencies. Further, the PROVIDER shall disclose the name of any State employee
who owns, directly or indirectly, an interest of five percent (50/0) or more in the PROVIDER's
firm or any of its branches. The PROVIDER covenants that it presently has no interest and shall
not acquire any interest, direct or indirect, which would conflict in any manner or degree with
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the performance of the services hereunder. The PROVIDER further covenants that it will not
employ any such person known to have such interests in the performance of the terms of this
Contract. No official or employee of the CTD or the CTC and no other public official of the State
of Florida or the federal government who exercises any functions or responsibilities in the
review or approval of the undertaking or carrying out the Contract shall, prior to completion of
this Contract, voluntarily acquire any personal interest, direct or indirect, in this Contract or
proposed Contract.
9. TERMINATION AND DEFAULT PROCEDURES
A. This Agreement may be canceled by the CTC in whole or in part at any time the interest
of the CTC requires such termination. The CTC reserves the right to terminate or cancel
this Agreement in the event an assignment is made for the benefit of creditors.
B. If the CTC determines that the performance of the PROVIDER is not satisfactory, the
CTC shall have the option of (a) immediately terminating the Agreement, or (b) notifying
the PROVIDER of the deficiency with a requirement that the deficiency be corrected
within a specified. time, otherwise the Agreement will be terminated at the end of such
time, or (c) taking whatever action is deemed appropriate by the CTC.
C. If the CTC requires termination of the Agreement for reasons other than unsatisfactory
performance of the PROVIDER, the CTC shall notify the PROVIDER of such termination,
with instructions as to the effective date of termination or specify the stage of work at
which the Agreement is to be terminated.
D. The PROVIDER shall submit a notice of withdrawal from the Transportation Provider
network at least ninety (90) calendar days priorto the effective date of such withdrawal.
E. In the event -funds to finance this Contract become unavailable, the CTC may terminate
the Contract upon no less than twenty-four (24) hours written notice to the PROVIDER.
Said notice shall be delivered by certified mail, return receipt requested, or in person
with proof of delivery. The CTC shall be the final authority as to the availability of
funds.
F. Termination for Breach. Unless the PROVIDER's breach is waived by the CTC in writing,
the CTC may, by written notice to the PROVIDER, terminate this Contract upon no less
than twenty-four (24) hours written notice. Said notice shall be delivered by certified
mail, return receipt requested, or in person with proof of delivery. If applicable, the CTC
may employ the default provisions in Chapter 60A-I006( 4), Florida Administrative Code.
Waiver of breach of any provisions of this Contract shall not be deemed to be a waiver
of any other breach and shall not be construed to be a modification of the terms of this
Contract. The provisions herein do not limit the CTC's right to remedies at law or to
damages.
In accordance with 1932(e)(4), Social Security Act, the CTC shall provide the PROVIDER
with an opportunity for a hearing prior to termination for breach. This does not
preclude the CTC from terminating without breach.
G. Upon receipt of final notice of termination, on the date and to the extent specified in the
notice of termination, the PROVIDER shall:
1) Stop work under the Contract, but not before the termination date;
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2) Take such action as may be necessary, or as the CTC may direct, for the
protection of property related to the Contract that is in the possession of the
PROVIDER and in which the CTC has been granted, or may acquire, an interest;
and
3) Not accept any payment after the Contract ends, unless the payment is for
services rendered before the Contract's termination effective date. The CTC may
withhold any payments due under the terms of this Contract until it receives all
written and properly executed documents from the PROVIDER as required by
written instructions from the CTC.
10. DAMAGES FOR FAILURE TO MEET CONTRACT REQUIREMENTS
In addition to any remedies available through this Contract, in law or equity, the PROVIDER
shall reimburse the CTC and/or AHCA for any federal disallowances or sanctions imposed on the
PROVIDER as a result of the PROVIDER's failure to abide by the terms of this Contract.
11. WAIVER
The parties shall not waive any covenant, condition, duty, obligation, or undertaking contained
in or made a part of this Contract except by written agreement of the parties, and forbearance
or indulgence in any other form or manner by either party in any regard whatsoever shall not
constitute a waiver of the covenant, condition, duty, obligation, or undertaking to be kept,
performed, or discharged by the party to which the same may apply. Until complete
performance or satisfaction of all such covenants, conditions, duties, obligations, or
undertakings, the other party shall have the right to invoke any remedy available under law or
equity not withstanding any such forbearance or indulgence.
12. INDEPENDENT PROVIDER
The parties expressly agree that the PROVIDER and any agents, officers, and/or employees of
the PROVIDER, in the performance of this Contract shall act inan independent capacity and not
as officers and/or employees of the CTC or the State of Florida. Furthermore, the parties
expressly agree that they shall not construe this Contract as having formed a partnership or
joint venture between the PROVIDER and the CTC and/or the State of Florida.
13. MISCELLANEOUS
A. ATTORNEY'S FEES. In the event of a dispute, each party to the Contract shall be
responsible for its own attorney's fees, except as otherwise provided by law.
B. COURT OF JURISDICTION OR VENUE For purposes of any legal action occurring as a
result of, or under, this Contract, between the erc and the PROVIDER, the place of
proper venue shall be Monroe -County.
C. FORCE MAJEURE. The CTC shall not be liable for any excess cost to the PROVIDER if
the CTC's failure to perform the Contract arises out of causes beyond the control and
without the result of fault or negligence on the part of the CTC. In all cases, the failure
to perform must be beyond the control without the fault or negligence of the CTC. The
PROVIDER shall not be liable for performance of the duties and responsibilities of the
Contract when its ability to perform is prevented by causes beyond its control. These
acts must occur without the fault or negligence of the PROVIDER. These include
destruction to the facilities due to hurricanes, fires, war, riots, and other similar acts.
D. LEGAL ACTION NOTIFICATION. The PROVIDER shall give the CTC, by certified mail,
immediate written notification (no later than thirty (30) Calendar Days after service of
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process) of any action or suit filed or of any claim made against the PROVIDER by any
Transportation Provider, or any other party which results in litigation related to this
Contract for disputes or damages exceeding the amount of $50,000. In addition, the
PROVIDER shall immediately advise the CTC of the Insolvency of the PROVIDER and/or
Transportation Provider or of the filing of a petition in bankruptcy by or against a
principal PROVIDER.
E. MISUSE OF SYMBOLS, EMBLEMS, OR NAMES IN REFERENCE TO MEDICAID. Neither the
PROVIDER nor any person may use, in connection with any item constituting an
advertisement, solicitation, circular, book, pamphlet or other communication, or a
broadcast, telecast, or other production, alone or with other words, letters, symbols or
emblems, the words "Medicaid," or "Agency for Health Care Administration," unless the
AHCA provides prior written approval. The PROVIDER must obtain specific written
authorization from the CTD in order to reproduce, reprint, or distribute any AHCA form,
application, or publication for a fee. State and local governments are exempt from this
prohibition. A disclaimer that accompanies the inappropriate use of program or AHCA
terms does not provide a defense. Each piece of mail or information constitutes a
Violation and is subject to sanctions.
F. OFFER OF GRATUmES. By signing this Contract, the PROVIDER signifies that, if
applicable, no member of, or a delegate of, Congress, nor any elected or appointed
official or employee of the State of Florida, the General Accounting Office, Department
of Health and Human Services, CMS, or any other federal agency has or shall benefit
financially or materially from this procurement. The CTC may terminate this Contract if it
is determined that gratuities of any kind were offered to, or received by, any officials or
employees from. the State, its agents, or employees.
G. EMERGENCY MANAGEMENT PLAN. The PROVIDER shall submit its plans describing
procedures ensuring the continuation of appropriate services during an emergency,
including but not limited to localized acts of nature, accidents, and technological and/or
attack-related emergencies, both natural and manmade. The PROVIDER shall provide a
copy of its disaster plan for written approval no later than thirty (30) days after the
effective date of this Contract and on June 1 of each year of this Contract, or at the
request of the CTC.
H. CULTURAL COMPETENCY PLAN. The PROVIDER shall comply with the Cultural
Competency Plan as developed by the CTc;.
I. The PROVIDER and its employees, agents, representatives are not employees of the
CTC and are not entitled to the benefits of State of Florida employees. Except to the
extent expressly authorized herein, PROVIDER and. its employees, agents,
representatives are not agents of the CTC or the State for any purpose or authority such
as to bind or represent the interests thereof, and shall not represent that it is an agent
or that it is acting on the behalf.of the CTC or the State. The CTC shall not be bound by
any unauthorized acts or conduct of the PROVIDER or its employees, agents,
representatives.
J. All words used herein in the singular form shall extend to and include the plural. All
words used in the plural form shall extend to and include the singular. All words used in
any gender shall extend to and include all genders.
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K. This Agreement embodies the whole agreement of the parties. There are no promises,
terms, conditions, or obligations other than those contained herein, and this Agreement
shall supersede all previous communications, representations, or agreements, either
verbal or written, between the parties hereto. The State of Florida terms and
conditions, whether general or specific, shall take precedence over and supersede any
inconsistent or conflicting provision in any attached terms and conditions of the
PROVIDER.
L. It is understood and agreed by the parties hereto that if any part, term or provision of
this Agreement is by the courts held to be illegal or in conflict with any law of the State
of Florida, the validity of the remaining portions or provisions shall not be affected, and
the rights and obligations of the parties shall be construed and enforced as if the
Agreement did not contain the particular part, term, or provision held to be invalid.
M. This Agreement shall be governed by and construed in accordance with the laws of the
State of Florida.
N. If this Agreement is the result of a formal solicitation (Invitation to Bid, Request for
Proposal or Invitation to Negotiate), the Department of Management Services Forms
PURIOOO and PURI001, included in the solicitation, are incorporated herein by reference
and made a part of this Agreement.
o. Time is of the essence as to each and every obligation under this Agreement.
-~ 0 ~ .."
P. The following Exhibits and Attachments are incorporated and made a~9!thf ~
Agreement:2;~3 I: 0
Exhibit A Scope of Services ~~~ ~...: N 6
Exhibit B Method of Compensation ('-) ~; ~~ C7\ ::0
Attachment 1 Business Associate Agreement ~:O F ~ ~
Attachment 2 Special Audit Requirements ::.:(~;:; Cf1 g
Attachment 3 Quarterly Grievance System Summary Report :q. (,'1 &- :0
Attachment 4 Trip Travel Expense Report i fl1 .... 0
Attachment 5 Business Disruption Notification Report
Attachment 6 Critical Incident Report
Attachment 7 Definitions and Acronyms
IN WITNESS WHEREOF, the parties have executed this Agreement by their duly authorized officers on
the day, month and year set forth above.
Guid nee/Care Center, Inc.
n
Maureen Grynewicz
Print/Type/Name and Date
1~/;)9 /oq
Authorized Signature
f'~- ,. Sylvia J. Murphv 01/20/2010'"
Print/Tvpe/Name and Date
Transportation Director
Title
Title
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EXHIBIT A
SCOPE OF SERVICES
Medicaid Non-Emergency Transportation Services
I. GENERAL OVERVIEW
A. Purpose
This Agreement between the erc and the PROVIDER is for the provision of Medicaid Non-
Emergency Transportation (NET) services.
B. General Responsibilities of the State of Florida (State) and the ere:
1 The erD will be responsible for setting policy relating to the Medicaid NET program.
2 The erc will administer the Agreement with the PROVIDER, monitor PROVIDER
performance, and provide oversight in all aspects of the PROVIDER's operations.
3 The State has sole authority for determining Medicaid eligibility.
4 Except for Medically Needy Medicaid Beneficiaries, eligibility for Transportation Services
provided by the Recipient is effective at 12:01 a.m. on the first (1st) Calendar Day of the
month.
5 The erc will conduct periodic monitoring of the PROVIDER's operations for compliance
with the provisions of the Agreement and applicable fed~ral, State, and local laws and
regulations.
6 The CTC has final authority in interpreting the terms and conditions of the Agreement
and analyzing all policies relating to the Agreement.
7 Unless otherwise specified in this Agreerrtent, the erc shall respond to all PROVIDER
requests for a response within ten (10) Business Days of receipt of said request.
8 The CTC shall ensure that the PROVIDER is Cost Effective (see Section 409.912(44),
F.S.). The ere may not renew this Agreement if it is not Cost Effective.
C. General Responsibilities of the PROVIDER
1 The PROVIDER shall comply with all provisions of this Agreement and its amendments, if
any, and shall act in good faith in the performance of the Agreement's provisions. The
PROVIDER shall comply with all written policies and procedures developed by the ere to
implement all. provisions of this Agreement. The PROVIDER agrees that failure to comply
with any provision of this Agreement shall result in the assessment of sanctions as
identified in this agreement.
2 The PROVIDER shaH comply with all requirements of Section 6032 (Employee Education
About False Claims Recovery) of the federal Deficit Reduction Act of 2005 if the
Recipient receives or earns five million dollars or more, annually, under the Medicaid
State plan.
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3 The PROVIDER shall comply with all pertinent ere rules in effect throughout the
duration of the Agreement.
4 The PROVIDER shall comply with all current Florida Medicaid Handbooks as noticed in
the Florida Administrative Weekly C'FAW"), or incorporated by reference in rules relating
to the provision of Transportation Services set forth in this agreement, except where the
provisions of the Agreement expressly alter the requirements set forth in the Florida
Medicaid Handbooks promulgated pursuant to the Florida Administrative Code (FAC). In
addition, the PROVIDER shall comply with the limitations and exclusions in the Medicaid
Handbooks, unless otherwise specified by this Agreement. In no instance may the
PROVIDER's limitations or exclusions imposed be more stringent than those specified in
the Medicaid Handbooks. The PROVIDER shall furnish Transportation Services in an
amount, duration, and scope that the PROVIDER may reasonably expect to achieve the
purpose for which the Transportation Services are furnished. The PROVIDER shall not
arbitrarily deny or reduce the amount, duration, or scope of Transportation Services
solely because of a Medicaid Beneficiary's diagnosis, type of illness, or condition.
5 This Agreement, including all attachments and exhibits, represents the entire agreement
between the PROVIDER and the erc and supersedes all other contracts, agreements, or
understandings between the parties when it is executed by duly authorized signatures of
the PROVIDER and the erc. Correspondence and memoranda of understanding do not
constitute part of this AgOreement. In the event of a conflict of language between the
Agreement and the exhibits and attachments, the provisions of the Agreement shall
govern.
6 The erc reserves the right to clarify any terms and conditions in question in regards to
the Agreement between the ere and the PROVIDER, in its sole discretion, in writing;
such clarification shall govern. Upon final determination of any dispute over any erc
decision, the PROVIDER shall proceed diligently with the performance of its duties as
specified under the Agreement and in accordance with the direction of the Agency's
Division of Medicaid.
7. The PROVIDER shall comply with the erc's Quality Improvement Program (QIP) to
ensure enhancement of quality of Transportation Services and emphasize the goals of
improving the quality of Transportation Services prOVided to Medicaid Beneficiaries. The
erc may sanction the PROVIDER, if the PROVIDER does not meet acceptable Quality
Improvement (QI) and Performance Measures (PMs), based on the erc's reports and
other outcome measures.
8. The PROVIDER must meet all requirements for doing business in the State of Florida.
9. The erc may require the PROVIDER to provide to the ere, or its Agent, information or
data that is not specified under this Agreement. In such instances, and at the direction
of the erc, the PROVIDER shall fully cooperate with such requests and furnish all
information in a timely manner, in the format in which the erc requested. The
PROVIDER shall have at least thirty (30) Calendar Days to fulfill such ad hoc requests.
10. The PROVIDER shall monitor utilization of Transportation Services by Medicaid
Beneficiaries through the Prior Authorization of claims for Covered Services and the
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reports specified in this agreement.
11. The PROVIDER shall collect and submit Encounter Data for each Agreement Year in the
format set forth in the Reporting Requirements section of this agreement, or as required
by the ere, and within the time frames specified by the erc. All Covered Services
rendered to Medicaid Beneficiaries shall result in the creation of an encounter record.
12. The PROVIDER shall not:
a. Use Fee-for-Service ambulance transport in lieu of Cost Effective and appropriate
Transportation Services;
b. Limit Medicaid Beneficiaries to a specific number of medical Trips for any specific
time period; and/or,
c. Limit Medicaid Beneficiaries to specific Licensed Health Care Professionals or use
similar limitations that restrict the distance required for a Medicaid Beneficiary to
receive Transportation Services, or limit the number of Trips provided to
Medicaid Beneficiaries.
13. Use of Funding for Lobbying or Advocacy Purposes
a. The erc shall ensure that neither the erc nor the PROVIDER use Medicaid
funding to lobby, advocate, or encourage other parties to lobby or advocate
legislators or other political leaders in violation of State and federal law. If the
ere determines that the PROVIDER has violated this requirement against
lobbying or advocating, the erc may sanction the PROVIDER.
b. The Recipient shall ensure that the Providers execute a Certificate Regarding
Lobbying no less than thirty (30) Calendar Days before the effective date of the
Agreement and maintain copies of said Certificates in the Recipient's files.
c. All of the lobbying and advocating requirements set forth in this Agreement apply
to staff, Subcontractors, Transportation Providers, Recipient volunteers,
employees, independent contractors, and all persons acting for, or on behalf of,
the Recipient. The requirements set forth in this Section shall govern the
development of all materials. Additionally, the Recipient is vicariously liable for
any Violations of its Subcontractors, Transportation Providers, agents,
employees, staff, and/or independent contractors.
II. BENEFICIARY ELIGIBILITY
A. Eligibility
1. Eligible Populations
a. The PROVIDER shall provide Medicaid Transportation Services only to Medicaid
Beneficiaries who are included in the eligible population.
b. The categories of eligible Medicaid Beneficiaries authorized to receive services
from the Recipient include, but are not limited to, the following:
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(1) Low Income Families and Children;
(2) Foster Care Children;
(3) Sixth Omnibus Budget Reconciliation Act (SOBRA) Children and pregnant
women;
(4) Supplemental Security Income (SSI) Medicaid only Medicaid Beneficiaries;
(5) SSI Medicare, Part B only Medicaid Beneficiaries;
(6) SSI Medicare, Parts A and B Medicaid Beneficiaries;
(7) Medicaid Beneficiaries who are residents in ALFs;
(8) The MEDS Aged/Disabled (AD) population;
(9) Individuals with Medicare coverage (e.g., dual eligible individuals) who
are not enrolled in a Medicare-funded Managed Care Organization (MCO);
(10) Institutional Care Program (ICP) Residents: Beneficiaries who are eligible
for transportation services for placement in a facility while their eligibility
determination is being processed (e.g., nursing home residents, etc.);
(11) Presumptively Eligible Pregnant Women: This program allows staff at
County Health Departments, Regional Prenatal Intensive Care Centers,
and other qualified medical facilities to make a presumptive determination
of Medicaid eligibility for low-income pregnant women. This presumptive
determination allows a woman to access prenatal care while Department
of Children and Families eligibility staff make a regular determination of
eligibility. Outpatient or office services related to the pregnancy are
reimbursed by this program; transportation services are available to
support these visits;
(12) Medicaid Beneficiaries who are receiving services through:
(a) A hospice program;
(b) A Prescribed Pediatric Extended Care (PPEC) center;
(c) The Aged/Disabled Adult Waiver;
(d) The Alzheimer's Disease Waiver;
(e) The Assisted Living for the Elderly Waiver;
(f) The Channeling Waiver;
(g) The Familial Dysautonomia Waiver;
(h) The Florida Senior Care Waiver;
(i) The Model Waiver;
(j) The Nursing Home Diversion Waiver;
(k) The Project AIDS Care Waiver; or
(I) The Traumatic Brain Injury/Spinal Cord Injury (TBljSCI) Waiver.
(13) Title XXI MediKids: A Title XXI health insurance program that provides
certain children, who are not Medicaid eligible, with Medicaid benefits;
and
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(14) Medically Needy: A Medically Needy beneficiary is an individual who
would qualify for Medicaid but has income or resources that exceed
normal Medicaid guidelines. On a month-by-month basis, the individual's
medical expenses are subtracted from income; if the remainder falls
below Medicaid's income limits, the individual may qualify for Medicaid
through the end of the month.
2. Ineligible Populations
a. The following categories describe Medicaid Beneficiaries who are not eligible to
receive Transportation Services from the Recipient:
(1) Medicaid MCO enrollees - Medicaid Beneficiaries who are enrolled with a
Medicaid MCO that provides Transportation;
(2) Medicaid Beneficiaries who have their own means of Transportation;
(3) Medicaid Beneficiaries who, at the time of application for enrollment
and/or at the time of enrollment, are domiciled or residing in an
institution, including:
(a) Statewide jnpatient psychiatric program (SIPP) facilities;
(b) Intermediate care facility for persons with developmental
disabilities (ICF-DD);
(c) State Hospitals; or
(d) Correctional institutions.
(4) Qualified Medicare Beneficiaries ("QMBs"), Special Low Income Medicare
Beneficiaries ("SLMBs"), Qualified Medicare Beneficiaries Renal Dialysis
("QMBRs'l, or Qualified Individuals at Level 1 ("QI1s'l;
(5) Medicaid Beneficiaries who reside in the following:
(a) Residential commitment programs/facilities operated through the
Department of Juvenile Justice (DJJ);
(b) Residential group care operated by the Family Safety &
Preservation Program of the Department of Children and Families
(OCF);
(c) Children's residential treatment facilities purchased through the
Substance Abuse & Mental Health District (SAMH) Offices of the
OCF (also referred to as Purchased Residential Treatment Services
- PRTS);
(d) SAMH residential treatment facilities. Licensed as Level I and Level
II facilities; and
(e) Residential Level I and Level II substance abuse treatment
programs. See Sections 65D-30.007(2)(a) and (b), F.A.C.
(6) Legal aliens;
(7) Medicaid Beneficiaries who are also members of a Medicare-funded
Managed Care Organizations (MCOs);
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(8) Medicaid Beneficiaries who are enrolled in the Family Planning Waiver;
and/or
(9) Medicaid Beneficiaries who are enrolled in the Program of All-inclusive
Care for the Elderly (PACE).
b. The following waivers' services are not eligible for Transportation Services:
(1) The Developmentally Disabled Waiver (Tier 1);
(2) The Developmentally Disabled Waiver (Tier 2);
(3) The Developmentally Disabled Waiver (Tier 3);
(4) The Family and Supported Living Waiver (Tier 4); and
(5) The Adult Cystic Fibrosis Waiver.
B. Gate Keeping
1. Medicaid Compensable Trips
a. Neither the CTC or the PROVIDER shall not require written verification from the
Medicaid Beneficiary as to the need for an Urgent Trip or Medically Necessary
Tri p.
b. TheCTC, and the Provider in its efforts to ensure proper Gate Keeping, may:
(1) Contact the Medicaid Beneficiary's provider's/Licensed Health Care
Professional's office and ask if the medical care is Medicaid compensable.
If the Trip is not Medicaid compensable, the PROVIDER shall deny the
Trip request.
(2) Contact the Medicaid Beneficiary's provider's/Licensed Health Care
Professional's office and ask if the Medicaid Beneficiary has an
appointment. If the Medicaid Beneficiary does not have an appointment,
the PROVIDER shall deny the Trip request.
(3) Contact the Medicaid Beneficiary's provider's/Licensed Health Care
Professional's office and ask if the medical care is considered Urgent Care
as defined in this Agreement. If the PROVIDER is able to confirm that the
Trip is not considered Urgent Care, the PROVIDER may require that the
Medicaid Beneficiary reschedule the requested Medicaid compensable
Tri p.
c. The PROVIDER can require that a Medicaid Beneficiary seek Medicaid
compensable services from a physician/Licensed Health Care Professional doing
business in the Medicaid Beneficiary's city/community of residence unless:
(1) There is not a physician/Licensed Health Care Professional in the
Medicaid Beneficiary's city/community of residence that can or will
provide services to the Medicaid Beneficiary;
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(2) The Medicaid Beneficiary has started a course of treatment for an Acute
Condition in one county of residence and subsequently changes his
county of residence to an adjacent county of residence. Upon completion
of a course of treatment for an Acute Condition, the Recipient may
require the Medicaid Beneficiary utilize the services of a provider/Licensed
Health Care Professional located in the Medicaid Beneficiary's
city/community of residence; or
(3) The Medicaid Beneficiary's provider/Licensed Health Care Professional is
located in an adjacent city/community and is at a distance no further
from the Medicaid Beneficiary's home than a similar physician/Licensed
Health Care Professional in the Medicaid Beneficiary's city/community of
residence.
d. The PROVIDER shall not limit the number of Medicaid compensable Trips that a
Medicaid Beneficiary receives.
e. In order to manage the coordination of Transportation Services, the PROVIDERs
may request that a Medicaid Beneficiary reschedule a Medicaid compensable Trip
that is not an Urgent Trip, but in no event may the PROVIDERs and/or
Transportation Providers delay the Medicaid Beneficiary's appointment by more
than fifteen (15) Business Days.
2. Neither the Agency for Health Care Administration, the.CTC, nor-the PROVIDER shall
limit the following types of Trips. The PROVIDER shall provide the following types of
Trips in addition to the PROVIDERs daily Trip allocation:
a. Urgent Trips
b. Trips to the following types of services:
(1) Dialysis;
(2) Chemotherapy;
(3) Wound treatment;
(4) Behavioral Health Care;
(5) Prescribed Pediatric Extended Care centers (PPECs); or,
(6) Any other Trip not speCifically set forth above, but that the Agency for
Health Care Administration determines, after consultation with the CTC, is
in the best interests of the Medicaid Beneficiary population.
3. The PROVIDERs shall comply with the following gate keeper responsibilities:
a. Accept requests for Transportation Services directly from Medicaid Beneficiaries,
adult family members on behalf of minor Medicaid Beneficiaries, guardians
responsible for Medicaid Beneficiaries, and providers/Licensed Health Care
Professionals on behalf of Medicaid Beneficiaries.
b. Assure that the Medicaid Beneficiary is a resident of Florida and is currently
Medicaid eligible. Medicaid eligibility shall be obtained by contacting a MEVS
vendor or similar provider, including the PROVIDERs eligibility verification
program, through FAXBACK with the Medicaid Fiscal Agent where a fax is sent
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through an automated system and a report is transmitted back containing
Beneficiary eligibility information.
c. Determine if transportation resources exist within the Medicaid Beneficiary's
Household regularly and/or specifically for the Trip requested, and may deny a
Trip request if the Medicaid Beneficiary has appropriate transportation resources
in his/her Household.
d. Determine if there is a. reason why the Medicaid Beneficiary cannot utilize his/her
own transportation (such as the vehicle is broken, out of gas, etc.). If the
Beneficiary is unable to utilize his/her transportation, the PROVIDER may assist
the Medicaid Beneficiary in utilizing his/her own means of transport (fix vehicle,
sl:lpply gas, etc.).
e. Determine whether any person who does not reside in the Medicaid Beneficiary's
household can reasonably provide transportation. "Reasonably" is defined to
mean both willing and able. The PROVIDER shall not demand the use of
transportation resources available through any party residing outside the
Medicaid Beneficiary's household.
f. Require the use of public transportation, where available and appropriate, for
Medicaid Beneficiaries who are able to understand common signs and directions.
g. Determine if the Medicaid Beneficiary is ambulatory, requires a mobility device,
or requires a stretcher for transport. The PROVIDER shall transport Medicaid
Beneficiaries who must use a mobility device for ambulation or must remain in a
lying position in vehicles appro'priate to their level of need.
h. Provide Transportation Services only to a Medicaid compensable service.
i. Refuse to reimburse the cost of transportation provided for a Medicaid
Beneficiary by any relative or member of the same household, exclusive of foster
parents.
j. Some nursing facilities, group homes, and personal care homes have one or
more vehicles, which are intended to facilitate the general administration of the
facility ,and not necessarily to provide for resident transportation. The PROVIDER
cannot deny Transportation Services based on the mere existence of a vehicle.
The availability of a vehicle for resident transportation must be determined on a
case by case basis. If the vehicle is not available for resident transportation at
the time required, as represented by the nursing facility manager or director of
nursing,as applicable, the PROVIDER shall exclude such vehicle as an alternate
form of available transportation.
k. Consider information presented by or on behalf of a Medicaid Beneficiary relative
to the need for Transportation Services upon each such request for
transportation, notwithstanding previous denials of service.
I. Except as otherwise specified below, require that a Medicaid Beneficiary and
associated Attendant/Escort be picked up from, and returned to, a common
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address.
m. Ensure that Medicaid is the payor of last resort and that the Medicaid Beneficiary
does not have access to any other form of transportation service to a Medicaid
compensable service.
5. If the PROVIDER requires an application process to determine eligibility for
Transportation Services, the PROVIDER shall provide Transportation Services to all
Medicaid Beneficiaries requiring Urgent Trips pending the PROVIDER's final eligibility
determination.
III. MEDICAID BENEFICIARY SERVICES
A. Medicaid Beneficiary Services
1. General Provisions
a. The PROVIDER shall have written policies and procedures for the provision of
Transportation Services, as specified in this Agreement
b. The PROVIDER shall ensure that Medicaid Beneficiaries are aware of their rights
and responsibilities, how to obtain Transportation Services, what to do in an
Emergency or Urgent Care situation, how to file a Complaint, Grievance, Appeal,
or Medicaid Fair Hearing, how to report suspected Fraud and Abuse, and all
other requirements and Covered Services.
c. The PROVIDER shall have the capability to answer Medicaid Beneficiary inquiries
via written materials, telephone, electronic transmission, and face-to-face
communication.
d. The PROVIDER shall not charge the CTC, CTD or Agency for Health Care
Administration or Medicaid Beneficiaries for printing written materials.
e. The PROVIDER must ma'ke oral interpretation services available free of charge to
non-English speaking Medicaid Beneficiaries. This applies to all non-English
languages, not just those that the State identifies as prevalent. The PROVIDER
shall not charge the CTC, CTD or Agency for Health Care Administration or the
Medicaid Beneficiary for interpretation services. The PROVIDER shall notify all
Medicaid Beneficiaries that oral interpretation is available for any language and
written information is available in prevalent languages, and how to access those
services.
2. Medicaid Beneficiary ,Communications
a. Requirements for all Communications
(1) The CTD and the AHCA must approve, in writing, all written, website and
verbal communications developed by the PROVIDER for
distribution/transmission to Medicaid Beneficiaries before communication.
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(2) The PROVIDER shall make all written communications available in
alternative formats and in a manner that takes into consideration the
Medicaid Beneficiary's special needs, including those who are visually
impaired or have limited reading proficiency (e.g., Braille, large print
format, etc.). The PROVIDER shall notify all Medicaid Beneficiaries that
information is available in alternative formats and how to access those
formats.
(3) The PROVIDER shall make all written communications available in
English, Spanish, and ~II other foreign languages in a county spoken by
five percent (50/0) or more of the total county population.
(4) The PROVIDER shall provide Medicaid Beneficiary information in
accordance with 42 CFR 438.10, which addresses information
requirements related to written and oral communications provided to
Medicaid Beneficiaries, including: languages, format, Transportation
Services, Service Area, and the Grievance System. The PROVIDER shall
notify Medicaid Beneficiaries on at least an annual basis of their right to
request and obtain information in accordance with the above regulations.
(5) All written materials shall be at or near the fourth (4th) grade reading
comprehension level. Suggested reference materials to determine
whether the PROVIDER's written material_s meet this requirement are:
(6) The PROVIDER shall provide written notice to the erc of any changes to
any correspondences, templates for mass mailings, and/or written
materials provided to Medicaid Beneficiaries. The erc shall review and
shall submit all written materials to the AHCA at least forty-five (45)
Calendar Days before the effective date of the change. The PROVIDER
shall provide written notice of changes to the Medicaid Beneficiary
Trans'portation Handbook and any policy changes to Medicaid
Beneficiaries at least thirty(30) Calendar Days before the effective date of
the change, but not before the erc and the AHCA approves, in writing,
the PROVIDER's written notice.
b. The PROVIDER shall mail any other mutually agreed upon notices at a date and
time agreed to by the Agency for Health Care Administration and the erc.
c. The PROVIDER shall not mail or give any written communications to Medicaid
Beneficiaries without first obtaining AHCA's written approval of the
communication via the erc.
d. The erc shall sanction the PROVIDER, in accordance with the contract, for any
failure on the part of the PROVIDER to obtain the ere's written approval before
disseminating written materials to Medicaid Beneficiaries.
3. Notice of Eligibility and Medicaid Beneficiary Transportation Services Handbook
a. Within seven (7) Calendar Days following the PROVIDER's.determination of a
Medicaid Beneficiary's eligibility to receive Transportation Services, the
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PROVIDER shall mail each Medicaid Beneficiary a ,copy of its Medicaid Beneficiary
Transportation Services Handbook.
b. The Medicaid Beneficiary Transportation Services Handbook shall include the
following information:
(1) A Table of Contents;
(2) The PROVIDER's toll-free Trip scheduling telephone number;
(3) Information to explain the different types of coverage available and the
time frames for requesting and receiving Transportation Services;
(4) Directions on the use of Transportation Services offered by the
PROVIDER;
(5) The extent to which, and how, the PROVIDER provides non-business
hour, inpatient delivery/return, Urgent Care delivery/return, and
Emergency Room discharge Transportation Services; ,
(6) An explanation of the Grievance System, including the address, telephone
number, and office hours of the PROVIDER's Grievance staff and the
CTC's Ombudsman. The PROVIDER shall specify phone numbers for a
grievant to call to present a Complaint, Grievance, or Appeal. Each phone
number shall be toll-free within the grievant's geographic area and
provide reasonable access to the PROVIDER and/or CTC without undue
delays;
(7) Medicaid Beneficiary rights and responsibilities;
(8) Information on Emergency Transportation and how to access those
services;
(9) Information on oral interpretation services for all languages and
alternative communication formats are available, free of charge, and how
to access these services;
(10) Information that the Medicaid Beneficiary's Transportation Services can
continue if the Medicaid Beneficiary files a Complaint, Grievance, or
Appeal of a denied authorization and that the Medicaid Beneficiary may
have to pay in case of an adverse ruling;
(11) Co-payments for the Medicaid Beneficiary;
(12) Instructions explaining how Medicaid Beneficiaries may obtain information
from the CTC regarding the Quality Improvement Plan and Performance
Measure indicators, including Medicaid Beneficiary information;
(13) Procedures for reporting Fraud, Abuse, and Overpayment;
(14) Information regarding HIPAA relative to the Medicaid Beneficiary's
personal. health information; and,
(15) Information relating to the PROVIDER's Medicaid Beneficiary No Show
Policy .
c. The Medicaid Beneficiary Handbook must clearly specify all necessary procedural
steps for filing Complaints, Grievances, Appeals, and Medicaid Fair Hearings,
including:
(1) Medicaid Beneficiary rights to file Complaints, Grievances, and. Appeals
and all requirements and time frames for filing Complaints, Grievances,
and Appeals.
(2) The CTC's and PROVIDER's Grievances and Appeals Coordinator's
address, toll-free telephone number and office hours.
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(3) The availability of assistance to Medicaid Beneficiaries in filing Grievances,
Appeals, and Medicaid Fair Hearings.
(4) The rules that govern representation at the Medicaid Fair Hearing.
(5) A statement explaining the Medicaid Beneficiary's right to request a
continuation of Transportation Services during an Appeal and/or Medicaid
Fair Hearing and a statement that if the Medicaid Fair Hearing upholds
the PROVIDER's Action, the PROVIDER may hold the Medicaid Beneficiary
liable for the cost of any continued Transportation Services.
(6) A detailed explanation of the proper procedure for a Medicaid Beneficiary
to request a continuation of Transportation Services during an Appeal
and/or Medicaid Fair Hearing.
B. No Show Beneficiary Education
1 If a Medicaid Beneficiary fails to provide notice of a cancellation to the PROVIDER at
least twenty-four (24) hours in advance of a scheduled Trip, or the Medicaid Beneficiary
is not available, or has decided he/she does not require Transportation Services, then
the PROVIDER shall classify the Medicaid Beneficiary as a No Show. The PROVIDER shall
provide the erc a monthly report listing it's No Show Medicaid Beneficiaries. The No
Show Medicaid Beneficiary report shall include the Medicaid Beneficiary's name, phone
number, date and time scheduled for transport, and Trip destination.
2 The PROVIDER shall contact the Medicaid Beneficiaries who are identified as No Shows
and counsel them on the proper usage of NET services and provide technical assistance.
The PROVIDER shall track the Medicaid Beneficiaries it counseled regarding the No
Show policy and keep a record of the technical assistance provided. The PROVIDER shall
take no action to "lock-in" a Medicaid Beneficiary without written approval provided by
the Agency for Health Care Administration's Project Manager. The erc shall maintain a
copy of the AHCA written approval in the PROVIDER's contract file.
. 3 If the No Show Medicaid Beneficiary provides acceptable, verifiable evidence to the
PROVIDER that the No Show was due to unforeseen and unavoidable circumstances, the
PROVIDER shall not count the missed Trip as a No Show, unless such evidence does not
prove the Medicaid Beneficiary was unable to meet the scheduled pick-up time due to
said unforeseen and unavoidable circumstances.
c. Co-Payments
1 The PROVIDER may charge a co-payment from Medicaid Beneficiaries that is not greater
than one dollar ($1.00) for each Trip or two dollars ($2.00) per each round Trip. The
PROVIDER must explain the PROVIDER's co-payment plan as part of the PROVIDER's
co-payment plan in the Medicaid Beneficiary Transportation Services Handbook.
2. The following categories of Medicaid Beneficiaries are not required to pay a copayment:
a. Medicaid Beneficiaries under twenty-one (21) years of age;
b. Pregnant women when the Transportation Services relate to:
(1) The pregnancy;
(2) To any medical condition that may complicate the pregnancy; or
(3) Conditions or complications of the pregnancy extending through the end
of the month in which the sixty (60) day period following termination of
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pregnancy ends.
c. Institutional Care Program (ICP) Medicaid Beneficiaries who are required to
spend all of their income for medical care costs (except for a minimal amount
that is required for personal needs) as a condition of receiving services in an
institution and who are inpatients in long-term care facilities, Hospitals, or other
medical institutions;
d. Medicaid Beneficiaries when Transportation Services relate to family planning
services; and,
e. Medicaid Beneficiaries who are receiving hospice services.
3. A PROVIDER cannot deny Transportation Services to a Medicaid Beneficiary based solely
on the Medicaid Beneficiary's inability to pay a Medicaid co-payment. If the Medicaid
Beneficiary is unable to pay for Transportation Services at the time the Transportation
Provider renders Transportation Services, the PROVIDER may bill the Medicaid
Beneficiary for the unpaid charge.
D. Cultural Competency
1. The PROVIDER shall comply with the erc's written Cultural Competency Plan, in
accordance with 42 CFR 438.206, to ensure Transportation Services are provided in a
culturally competent manner to all Medicaid Beneficiaries, including those with limited
English proficiency. The Cultural Competency Plan explains that PROVIDERs and
PROVIDER employees will provide effective Transportation Services to people of all
cultures, races, ethnic backgrounds, and religions in a manner that recognizes, values,
affirms, and respects the worth of the individual Medicaid Beneficiaries and protects and
preserves the dignity of each Medicaid Beneficiary.
IV. COVERED SERVICES
A. Covered Services
1 The PROVIDER shall ensure the provision of Transportation Services in sufficient
amount; duration, and scope reasonably expected to achieve the purpose for which the
Transportation Services are furnished and shall ensure the provision of the following
Covered Services as defined and specified in this Agreement. The PROVIDER shall not
arbitrarily deny or reduce the amount, duration, or scope of Transportation Services
solely because of a Medicaid Beneficiary's diagnosis, type of illness, or condition.
2 The PROVIDER is responsible for ensuring that it incorporates all Transportation
Provider, service, and product standards specified in the Agency's Non-Emergency
Transportation Services Coverage & Limitations Handbooks and the erc's handbooks
into the PROVIDER's Transportation Provider Agreement by reference.
3 Medicaid Beneficiaries who have begun self-administered home oxygen before transport
may continue administration during transport. However, a Medicaid Beneficiary cannot
begin a new regimen of oxygen therapy during transport, nor may the attendant
employed by the Transportation Provider administer oxygen.
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4. Escort Services - An Attendant/Escort is an individual whose presence is required to
assist a Medicaid Beneficiary during transport and at the place of treatment. The
Attendant/Escort leaves the vehicle at its destination and remains with the Medicaid
Beneficiary. An Attendant/Escort must be of an age of legal majority recognized under
Florida law.
a. The PROVIDER must allow, without charge to the Escort or Medicaid Beneficiary,
one (1) Attendant/Escort to accompany a Medicaid Beneficiary or group of
Medicaid Beneficiaries who are blind, deaf, mentally disabled, or under twenty-
one (21) years of age, when the Medicaid Beneficiaries are transported to
receive Medicaid compensable services.
b. Upon the request of a Prescribed Pediatric Extended Care (PPEC) Center, the
PROVIDER shall pick up' Escorts for children attending said PPEC at a mutually
agreed upon location from the Medica'id Beneficiary before picking up the
Medicaid Beneficiary who is traveling to the PPEC. The PROVIDER shall not drop
off the Escort until after the PROVIqER has dropped off the PPEC Medicaid
Beneficiary.
s. Special Covered Services - The PROVIDER must supply Transportation for Medicaid
Beneficiaries when:
a. The Agency for Health Care Administration has begun a closure or decertification
of a Nursing Facility and Medicaid Beneficiaries require Transportation from one
Nursing Facility to another or to an alternate living arrangement; or,
b. A Medicaid Beneficiary has a change in level of care that results in the facility not
being certified or equipped to provide medically required or specialized services
and the Medicaid Beneficiary requires Transportation from one Nursing Facility to
another Nursing Facility or to an alternative living arrangement.
6. The PROVIDER shall provide Transportation Services for the following Covered Services:
a. The PROVIDER must provide Transportation Services to eligible Medicaid
Beneficiaries for Medicaid compensable services by using the most appropriate
mode of Transportation, including, but not limited to, the following types:
(1) Multiload Vehicles - A multiload vehicle is a multiple passenger vehicle,
typically used for Transportation Services. It is appropriate only for
ambulatory or non-ambulatory persons who can enter and exit a vehicle
with minimal to no assistance. Assistance means that additional
equipment and time are required. Multiload vehicles may include buses,
vans, sedans, and taxis.
(2) Wheelchair Vehicle - A wheelchair vehicle is a motorized vehicle equipped
specifically with certified wheelchair lifts, or other equipment designed to
carry persons in wheel~hairs and scooters, or with mobility impairments.
The PROVIDER may use wheelchair vehicles for the provision of
ambulatory transportation services to maximize capacity.
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(a) The PROVIDER must use wheelchair vehicles in the following NET
situations:
(i) Medicaid Beneficiaries who are continually confined to a
wheelchair;
(ii) Medicaid Beneficiaries with severe mobility handicaps that
prevent them from using private or public transportation or
taxis;
(iii) Medicaid Beneficiaries who are semi-ambulatory or
homebound, and can accomplish limited ambulatory
movement with the assistance of a special ambulatory aid
(like a walker or cane); or,
(iv) Medicaid Beneficiaries who use a mobility device.
(b) In questionable cases, the PROVIDER may contact the office of
the Medicaid Beneficiary's Health Care Professional to verify.the
Medicaid Beneficiary's need for transport by a wheelchair vehicle.
(3) Public Transportation (where available) - In some areas of Florida, public
transportation may be a viable and Cost Effective alternative to more
traditional and expensive forms of Non-Emergency Transportation. For
purposes of this Agreement, public transportation is a.ny fixed-route
transportation service that is available to the general public.
(a) Transit companies, county or city governments, or federally
funded transportation authorities may provide public
transportation.
(b) The PROVIDER may use public transportation to provide a full
Trip, or portion of a Trip, to or from a Medicaid compensable
service.
(c) The intent of this section is to maximize the use of fixed-route
services.
(4) Private Volunteer Transportation (where available) - Private volunteer
transportation is provided by individuals or agencies that receive no
compensation or payment other than minimal reimbursement for Mileage
for the provision of private volunteer transportation services.
(a) The PROVIDER shall ensure that Medicaid Beneficiaries receive
Transportation Services from a volunteer organization,
including, if applicable, scheduling appointments, and notifying
Medicaid Beneficiaries of arrangements.
(b) The PROVIDER is responsible for all necessary payments
(excluding co-payments, if any) to the private volunteer
Transportation Provider.
(c) Use of volunteer transportation does not alleviate the PROVIDER's
responsibility to assure the safety, comfort, and appropriate mode
of Transportation consistent with the Medicaid Beneficiary's health
care status. The PROVIDER must ensure that all volunteers and
vehicles used to provide private volunteer transportation are
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properly Licensed and insured.
B. Excluded Services
1. The PROVIDER is not required to provide the following excluded services:
a. Stretcher Vehicle Oxygen Administration
(1) Stretcher Vehicle Transportation Providers are not required to be
equipped to maintain a ventilator or care for a Medicaid Beneficiary who
is ventilator-dependent during a transport.
b. Ground Ambulance Transportation
(1) The PROVIDER is excluded from providing ground ambulance transportation
if a local governmental ordinance mandates non-emergency stretcher
transportation services be provided in a ground ambulance vehicle.
c. Air Ambulance Transportation
d. Basic Life Support (BlS) and Advance Life Support (ALS) Transportation
C. Special Exclusions
1. The PROVIDER is not responsible for the coverage of:
a. The cost of transporting a Medicaid Beneficiary back to Florida when the
Medic;:aid Beneficiary voluntarily traveled outside of Florida and requires
hospitalization and/or subsequent Nursing Facility care, unless a Medicaid
Beneficiary received prior authorization to travel out of State for the purpose of
receiving a Medicaid compensable service;
b. Transportation for therapeutic home visits to or from a Hospital, hospice, nursing
home, ICF/DD, State, or other private or public institution;
c. Transportation of a Medicaid Beneficiary from one Hospital to another, one
Nursing Facility to another, or from a Hospital to a Nursing Facility, solely based
on the preference of the Medicaid Beneficiary or a member of the Medicaid
Beneficiary's family, except as otherwise set forth in this Agreement;
d. Transportation of deceased Medicaid Beneficiaries;
e. Transportation of family members to visit a hospitalized or institutionalized
Medicaid Beneficiary;
f. Transportation of a Medicaid Beneficiary to receive medical training;
g. Transportation of Medicaid Beneficiaries to a pharmacy for the purpose of having
a prescription filled;
h. Transportation of a Medicaid Beneficiary to a m.edical facility or physician's office
for the sole purpose of obtaining a medical recommendation or to pick up
Medical Records;
i. Transportation of a Medicaid Beneficiary for socialization and/or therapeutic field
visits to locations other than the facility where such services are received;
j. Transportation Services available to the general public free of charge;
k. Transportation Services that are already covered by a per diem rate and included
in a corresponding cost report. Transportation Services are included in an
ICF/DD's per diem;
I. Unless otherwise provided by State or federal law, the Recipient shall not pay
salaries, fees, or other compensation for professional health care
Attendants/Escorts;
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m. Transportation of a Medicaid Beneficiary to a service covered by a Home and
Community-Based Service (HCSS) waiver if transportation can be billed to the
waiver or is included in the reimbursement for the waiver service; or
n. Transportation Services to or from an Adult Day Care center.
V. TRANSPORTATION PROVIDER NETWORK
A. General Provisions
1. The CTC shall maintain a Subcontractor List for each county in which it provides
services. The list shall include, at a minimum, the following information for each
Subcontractor:
a. Name;
b. Mailing address (including street number, city, state, and zip code);
c. Main contact's name; .
d. Main contact's telephone number;
e. Main customer service telephone number;
f. Main fax telephone number; and,
g. E-mail address.
B. PROVIDERS/Subcontractors
1. Service Standards
a. The following standards are for all vehicles and drivers, excluding volunteer-
owned vehicles:
(1) Drug and Alcohol Testing - The PROVIDER and/or Transportation
Providers shall in compliance with the Federal Transit Administration's
(FTA) drug and alcohol regulations, and the Federal Highway
Administration's drug and alcohol regulations, where applicable.
(2) The FTA determines mandatory transportation safety standards based on
the size and nature of the Transportation Provider. The PROVIDER can
obtain full details of the FTA's safety standards from the Federal Transit
Administration, Office of Safety and Security, 400 7th Street, S.W.,
Washington D.C., 20590. While the CTD strongly recommends using the
FTA's guidelines, it is the CTC's responsibility to ensure that it and any
transportation providers are in compliance with all applicable federal,
State, and local regulations.
(3) Driver Accountability - The PROVIDER shall ensure that all drivers have a
valid driver's license and are covered by the CTC's, or Transportation
Provider's insurance plan, as required by law, before starting to provide
Transportation Services. The PROVIDER shall ensure that all drivers meet
the locally determined driver background screening standard before
providing Transportation Services to Medicaid Beneficiaries. The
PROVIDER must have ready access to all documentation of the above
listed requirements.
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(a) If a particular driver is not properly licensed or insured, the
PROVIDER shall remove the driver from all routes transporting
Medicaid Beneficiaries.
(4) Driver Conduct - The PROVIDER shall ensure that drivers act in a
professional manner at all times and shall perform the minimum levels of
service as explained in all Subcontracts.
(a) If the erc and/or PROVIDER receive Complaints and/or
Grievances regarding a particular driver, and it is determined that
the driver is not conducting himself/herself in a manner consistent
with the minimum levels of service, and corrective action has not
resulted in improved performance, the PROVIDER shall remove
the driver from all routes transporting Medicaid Beneficiaries.
(5) The PROVIDER shall use child safety restraints, if applicable, where the
use of such devices would not interfere with the. safety of a child (e.g., a
child is in a wheelchair).
(6) Where applicable, shall follow the rules and regulations of the Americans
with Disabilities Act.
2. Standards for Commercial and Volunteer Drivers:
a. Drivers and/or attendants shall not engage in activities including, but not limited
to, the following:
(1) Make sexually explicit comments towards, solicit sexual favors from, or
engage in sexual activity with Medicaid beneficiaries;
(2) Solicit or accept controlled substances, alcohol, or medications from
Medicaid beneficiaries;
(3) Solicit or accept money from Medicaid Beneficiaries other than authorized
co-payments;
(4) Use alcohol, n~rcotics, or controlled substances, or be under their
influence, while on duty. A driver/attendant may use prescription
medication so long as he/she can still perform his/her duties in a safe
manner and the PROVIDER has written documentation that the
driver's/attendant's medication will not impact his/her ability;
(5) Eat or consume any beverage while operating the vehicle or while
providing Transportation Services to Medicaid Beneficiaries;
(6) Smoke or use smokeless tobacco products in the vehicle;
(7) Wear any type of headphones while on duty; and/or,
(8) Be responsible for p.assenger's personal items.
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b. At a minimum, drivers/attendants shall:
(1) Wear, or have visible, easy to read identification that identifies the
driver/attendant as an employee of the PROVIDER;
(2) Unless the vehicle has a mechanism by which it can open and close the
door from the inside of the vehicle, exit the vehicle to open and close
vehicle doors when passengers enter or exit the vehicle;
(3) Properly identify and announce their presence at the entrance of the
buildings, or with attending facility staff, at the specified pick-up location
if a curbside pick-up is not appropriate;
(4) Assist Medicaid beneficiaries in seating, including the fastening of the seat
belt when necessitated by a Medicaid Beneficiary's condition;
(5) Confirm, prior to allowing any vehicle to proceed, that wheelchairs and
wheelchair passengers are properly secured; and that, when appropriate,
passengers are properly secured in their seat belts;
(6) Provide an appropriate level of assistance to Medicaid Beneficiaries when
requested or as needed due to a Medicaid Beneficiary's conditi.on. Such
assistance shall also apply to the movement of wheelchairs and persons
with limited mobility as they enter or 'exit the vehicle using the wheelchair
lift and shall include the driver stowing any mobility aids and folding
wheelchairs; and,
(7) Be clean and maintain an appearance while transporting Medicaid
Beneficiaries.
3. Vehicle Requirements
a. Maintenance - The PROVIDER shall maintain vehicles and equipment to meet
the requirements of the Agreement.
(1) Vehicles and all components shall meet or exceed the manufacturer,
state, and federal safety and mechanical operating and maintenance
standards for any and all vehicles and models used for transportation of
Medicaid Beneficiaries under the terms of the Contract.
(2) The PROVIDER shall comply with all applicable state and federal laws
including, but not limited to, the Americans with Disabilities Act (ADA)
and the Federal Transit Administration (FTA) regulations.
(3) The PROVIDER shall immediately remove from service any vehicle that
.does not meet or exceed the Florida Department of Highway Safety and
Motor Vehicles (DHSMV) licensing requirements, safety standards, ADA
regulations, or Agreement requirements and shall re-inspect such vehicle
before using it to provide Transportation Services to Medicaid
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benefici a ries.
(4) The PROVIDER shall not allow vehicles to transport more passengers
than the vehicle was designed to carry.
(5) All lift-equipped vehicles shall comply with ADA regulations.
4. Vehicle Inspections
a. The PROVIDER shall submit annual documentation certifying that all vehicles
meet the regulatory requirements. If it is determined during an inspection, filed
Complaint and/or Grievance, or other means, that a vehicle does not meet the
regulatory requirements, the PROVIDER or Transportation Provider, as
applicable, must immediately remove the vehicle from service. The PROVIDER
must provide documentation to the ere ensuring that the manufacturer or a
mechanic, certified by the National Institute for Automotive Service Excellence
(ASE), has corrected all deficiencies before the PROVIDER or Transportation
Provider can use the vehicle to transport Medicaid Beneficiaries.
b. All commercial vehicles shall meet or exceed the following requirements:
(1) All commercial Transportation Providers shall use a two-way
communication system linking all vehicles used in delivering
Transportation Services to Medicaid Beneficiaries with the Transportation
Provider's major place of business (dispatcher).
(2) The Transportation Provider shall use the two-way communication system
in such a manner as to facilitate communication and to minimize the time
in which it can replace or repair out-of-service vehicles.
(3) Pagers are not an acceptable su'bstitute for a two-way communication
system. Transportation Providers shall immediately remove from service
any vehicle with an inoperative two-way communication system until it
repairs or replaces the two-way communication system.
(4) The PROVIDER shall ensure that:
(a) All vehicles are equipped with climate control systems adequate
for the heating and ventilation needs of both driver and
passengers. The PROVIDER shall remove from service
immediately any vehicle with a non-functioning climate control
system until it repairs or replaces the system;
(b) All vehicles have functioning, clean, and accessible seat belts,
where applicable, for each passenger seat position and that the
seat belts are stored off the floor when not in use;
(c) Each vehicle utilizes child safety seats, where applicable, that
meet all State and federal guidelines. Each PROVIDER must show
proof that it has trained its drivers in the proper installation and
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use of child safety seats;
(d) All vehicles shall have functional door handles on all doors;
(e) All vehicles shall have an accurate speedometer and odometer;
(f) All vehicles shall have functioning interior light(s) within the
passenger compartment;
(g) All vehicles shall have adequate sidewall padding and ceiling
covering;
(h) All vehicles shall have two (2) exterior rear view mirrors, one (1)
on each side of the vehicle;
(i) All vehicles shall have at least one (1) interior mirror for
monitoring the passenger compartment;
(j) All vehicle interiors and exteriors are clean and free of broken
mirrors or windows, excessive grime, rust, chipped paint, or major
dents that detract from the overall appearance of the vehicle;
(k) All vehicles have passenger compartments that are clean, free
from torn upholstery or floor coverings, damaged or broken seats,
or protruding sharp edges and shall also be free of dirt, oil,
grease, or litter.
C. Minimum Standards
1 Access for Persons with Disabilities -All transportation facilities open to the public have
access for persons with disabilities.
2 Health, Cleanliness, and Safety -All transportation facilities (or services) owned,
operator and/or provided by the PROVIDER shall adequate space, supplies, proper
sanitation, and smoke-free transportation facilities with proper fire and safety
procedures in operation.
D. Coverage Provisions
1. Transportation Services shall be available on a timely basis, as follows:
a. Routine Trips
(1) Unless as otherwise set forth in this Contract, a Medicaid Beneficiary must
contact the PROVIDER before the close of business at least three (3)
Business Days before the Medicaid Beneficiary needs to receive
Transportation Services. The three (3) Business Days includes the day the
Medicaid BenefiCiary calls the PROVIDERs, but not the day of the
Medicaid Beneficiary's medical appointment.
b. Nursing Home and Behavioral Health Facility Transportation Services
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(1) The PROVIDER shall provide the appropriate level of Transportation
Services to Medicaid compensable services for Medicaid Beneficiaries who
are residents of nursing facilities, group homes, behavioral health
facilities, or assisted living facilities.
(2). If the Medicaid Beneficiary's facility provides free Transportation Services
for its residents to receive medical services, the facility must provide the
same Transportation Services at no charge to Medicaid; Beneficiaries who
reside at the facility. If the Medicaid Beneficiary's faciUty provides free
Transportation Services for its residents to receive medical services, the
PROVIDER is not required to supply Transportation Services to the
Medicaid Beneficiary.
(3) The PROVIDER shall provide Medicaid Beneficiaries who are residents of
nursing facilities, group homes, behavioral health facilities, or assisted
living facilities Transportation Services that are appropriate to the needs
and condition of the Medicaid Beneficiary. The PROVIDER shall coordinate
pick-up and return times for Medicaid Beneficiaries, especially those who
have physical conditions or limitations that may be exacerbated by
lengthy waiting periods, as verified by the facility.
2 The PROVIDER shall have written procedures in place for the provision of transportation
services during inclement weather conditions and/or declared emergencies as
determined by State, federal, or local officials.
a. Service Area
(1) Transportation Services under this contract will be provided within
Monroe County and shall be provided to all eligible Medicaid Beneficiaries
regardless of their county of residence.
E. Medicaid Beneficiaries. Needing Transportation Following Exercise of Baker Act
1 Transportation Services shall not be provided to transport a Medicaid Beneficiary from a
Hospital/facility to a Behavioral Health Care facility if the Medicaid Beneficiary is
receiving services pursuant to th~ Baker Act.
VI. OUALITY IMPROVEMENT
A. Quality Improvement
The erc shall have a Quality Improvement Program to monitor and evaluate the quality and
appropriateness of Transportation S~rvices rendered to Medicaid Beneficiaries.
1. General Requirements
a. PROVIDER will attend annual "best practices" seminars to learn how best to
coordinate Transportation Services and meet the needs of this.Agreement.
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b. The PROVIDER shall participate in Quality Improvement activities by the ere to
enhance the Quality of Transportation Services provided to Medicaid
Beneficiaries.
B. Performance Measures
1 In order to develop appropriate benchmarks, the PROVIDER shall report the following
performance measures by the start date established in the chart below:
2. For the Performance Measures that must begin reporting via Encounter Data on
January 1, 2010, the erc shall collect a sample of the data manually, as described
below, from those PROVIDERs that are not able to submit the information electronically
upon the date of commencement of Encounter Data submission.
a. Upon the start date of this Contract, the PROVIDER shall require all drivers to
record Performance Measure information on all driver manifests.
b. Upon the start date of this Contract, PROVIDERs shall monitor the driver
manifests on a monthly basis by examining a statistically significant sample of
driver manifests to determine the timeliness of reporting. The PROVIDERs shall
submit their on-time pickup and delivery report either directly to the erc using
the Medicaid Encounter Data System (MEDS System).The PROVIDER shall submit
the on time pickup and delivery reports using the MEDS System by
January 1, 2010.
c. Until the PROVIDER begins submitting Performance Measure information via the
MEDS System, PROVIDERs shall submit all Performance Measure information to
the erc for review to be submitted to the AHCA.
(1) If it is determined that a PROVIDER is excessively late in picking up
and/or delivering Medicaid Beneficiaries to their destinations, the erc or
the AHCA shall require the PROVIDER to initiate a Corrective Action Plan
(CAP) to explain how the PROVIDER will pick up and/or deliver Medicaid
Beneficiaries in a timely manner.
(2) If the PROVIDER is unable to meet the requirements set forth in the CAP
to pick up or deliver Medicaid Beneficiaries on time, the erc shall require
the PROVIDER to begin electronic submission of Performance Measure
information using the Encounter Data System, within sixty (60) Calendar
Days of the determination or by January 1, 2010, whichever comes first.
(2) Those PROVIDERs are to submit the Performance Measure information upon
the start date of this contract shall not be required to submit sampling
reports as described above.
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Start Date PM Description Source Methodology
(Where
Applicable)
Start Date of Agreement The number of accidents per Subcontractor Logs NjA
100,000 miles, broken down by
county.
Start Date of Agreement The number of Road Calls per Subcontractor Logs NjA
10,000 miles, broken down by
county.
Start Date of Agreement Average Medicaid Beneficiary call Recipient NjA
hold times on a county by county Survey jMonitoring
basis and as measured throughout
the year and at different times of
the day.
Starts upon Commencement The number of Medicaid Encounter Data Found by Subtracting
of Submission of Encounter Beneficiaries delivered to "Reservation Appointment
Data appointments later than the Time" by "Trip
scheduled appointment time, Destination Drop Off
broken down by county. Time"
Starts upon .Commencement The number of Medicaid Encounter Data Found by.Counting Each
of Submission of Encounter Beneficiary No Shows, broken "No Show" in the "Trip
Data down by county. Indicator" Field
01/01/2010 The average waiting time for a Encounter Data Found by.Subtracting
scheduled pickup, broken down "Trip Actual Pickup Time"
by county. by "Reservation Pick Up
Time"
01/01/2010 The average travel time that a Encounter Data Found by Subtracting
Medicaid Beneficiary must "Trip Actual Pickup Time"
remain in a vehicle from the by "Trip Destination Drop
point of pick up to the Off Time"
destination, broken down by
transportation mode and
county.
VII. GRIEVANCE SYSTEM
A. Overview
1. Description
a. Complaint process - The Complaint process is the erc's and the PROVIDER's
procedure for addressing Medicaid Beneficiary Complaints, which are expressions
of dissatisfaction about any matter other than an Action that are resolved at the
Point of Contact rather than through filing a formal Grievance.
b. Grievance process - The Grievance process is the erc's and the PROVIDER's
procedure for addressing Medicaid Beneficiary Grievances, which are expressions
of dissatisfaction about any matter other than an Action.
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c. Appeal process - The Appeal process is the CTC's and the PROVIDER's
procedure for addressing Medicaid Beneficiary Appeals, which are requests for
review of an Action.
d. Medicaid Fair Hearing process - The Medicaid Fair Hearing process is the
administrative process which allows a Medicaid Beneficiary to request the State
to reconsider an adverse decision made by the CTC or the PROVIDER.
2. General Requirements
a. The CTC and the PROVIDER shall. have a Grievance System in place that includes
a Complaint process, a Grievance process, an Appeal process, and access to the
Medicaid Fair Hearing system. The Grievance System shall comply with the
requirements set forth in Section 641.511, F.S., if applicable and with all
applicable federal and State laws and regulations, including 42 CFR 431.200 and
42 CFR 438, Subpart F, "Grievance System."
b. The PROVIDER must develop and maintain written policies and procedures
relating to the Grievance System. Before implementation, the CTC must give the
PROVIDER written approval of the PROVIDER's Grievance System. policies and
procedures
c. The PROVIDER shall refer all Medicaid Beneficiaries who are dissatisfied with the
PROVIDER or its Actions to the PROVIDER's Grievance/Appeal Coordinator for
processing and documentation in accordance with this Contract and established
policies and procedures.
d. The PROVIDER shall provide reasonable assistance to Medicaid Beneficiaries in'
completing forms and other procedural steps, including, but not limited to,
providing interpreter services and toll-free numbers with TTY {TOO and
interpreter capability.
e. The PROVIDER shall acknowledge, in writing, the receipt of a Grievance or a
request for an Appeal, unless the Medicaid Beneficiary requests an expedited
resolution
f. The PROVIDER shall not allow any of the decision makers on a Grievance or
Appeal were involved in any of the previous levels of review or decision-making
when deciding any of the following:
(1) An Appeal of a denial that is based on lack of Medical Necessity; and,
(2) A Grievance regarding the denial of an expedited resolution of an Appeal.
g. The Medicaid Beneficiary, and/or the Medicaid Beneficiary's representative, shall
be allowed an opportunity to examine the Medicaid Beneficiary's case file before
and during the Grievance or Appeal process, including all Medical Records and
any other documents and records
h. The Medicaid Beneficiary and/or the Medicaid Beneficiary's representative or the
representative of a deceased Medicaid Beneficiary's estate shall be considered as
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parties to the Grievance/Appeal.
i. The PROVIDER shall maintain, monitor, and review a record/log of all
Complaints, Grievances, and Appeals in accordance with the terms of this
Contract and to fulfill the reporting . requirements as set forth in this Contract.
j. The PROVIDER shall work with the CTC to resolve all grievance related issues.
k. Notice of Action
(1) The PROVIDER shall notify the Medicaid Beneficiary, in writing, using
language at, or below the fourth (4th) grade reading level, of any Action
taken by the PROVIDER to deny a Transportation Service request, or limit
Transportation Services in an amount, duration, or scope that is less than
requested.
(2) The PROVIDER shall provide notice to the Medicaid BenefiCiary as set
forth below (see 42 CFR 438.404(a) and (c) and 42 CFR 438.210(b) and
(c)):
(a) The Action the Recipient has taken or intends to take;
(b) The reasons for the Action, customized for the circumstances of
the Medicaid Beneficiary;
(c) The Medicaid Beneficiary's or the Health Care Professional's (with
written permission of the Medicaid Beneficiary) right to file an
Appeal;
(d) The procedures for filing an Appeal;
(e) The circumstances under which expedited resolution is available
and how to request it; and,
(f) The Medicaid Beneficiary's rights to request that Transportation
Services continue pending the resolution of the Appeal, -how to
request the continuation of Transportation Services, and the
circumstances under which the Medicaid Beneficiary may be
required to pay the costs of these services.
(3) The PROVIDER must provide the notice of Action within the following
time frames:
(a) At least ten (10) Calendar Days before the date of the Action or
fifteen (15) Calendar Days if ~he notice is sent by Surface Mail
(five [5] Calendar Days if the - Recipient suspects Fraud on the part
of the Medicaid Beneficiary). See 42 CFR 431.211, 42 CFR
431.213 and 42 CFR 431.214.
(b) For denial of the Trip request, at the time of any Action affecting
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the Trip request.
(c) For standard Service Authorization decisions that deny or limit
Transportation Services, as quickly as the Medicaid Beneficiary's
health condition requires, but no later than fourteen (14) Calendar
Days following receipt of the request for service (see 42 CFR
438.210(d)(1)).
(d) If the PROVIDER extends the time frame for notification, it must:
(i) Give the Medicaid Beneficiary written notice of the reason
for the extension and inform the Medicaid Beneficiary of
the right to file a Grievance if the Medicaid Beneficiary
disagrees with the Recipient's decision to extend the time
frame; and,
(ii) Carry out its determination as quickly as the Medicaid
Beneficiary's health condition requires, but in no case later
than the date upon which the fourteen (14) Calendar Day
extension period expires (see 42 CFR 438.210(d)(1)).
(e) If the PROVIDER fails to reach a decision within the time frames
described above, the Medicaid Beneficiary can consider such
failure on the part of the PROVIDER a denial and, therefore, an
Action adverse to the Medicaid Beneficiary (See 42. CFR
438.210(d)).
(f) For expedited Service Authorization decisions, within three
(3) Business Days (with the possibility of a fourteen (14) Calendar
Day extension). See 42CFR 438.210(d)(2).
B. The Complaint Process
1 A Medicaid Beneficiary may file a Complaint, or a representative of the Medicaid
Beneficiary, acting on behalf of the Medicaid Beneficiary and with the Medicaid
Beneficiary's written consent, may file a Complaint.
2. General Duties
a. The PROVIDER must:
(1) Resolve each Complaint within fifteen (15) Business Days from the day
the PROVIDER received the initial Complaint, be it oral or in writing;
(a) The PROVIDER may extend the Complaint resolution time frame
by up to ten (10) Business Days if the Medicaid Beneficiary
requests an extension, or documents that there is a need for
additional information and that the delay is in the Medicaid
Beneficiary's best interest.
(b) If the PROVIDER requests the extension, they must give the
Medicaid Beneficiary written notice of the reason for the delay.
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(2) Notify the Medicaid Beneficiary, in writing, within five (5) Business Days
of the resolution of the Complaint if the Medicaid Beneficiary is not
satisfied with the PROVIDER's resolution. The notice of disposition shall
include the results and date of the resolution of the Complaint, and shall
include:
(a) A notice of the right to request a Grievance or Appeal, whichever
is the most appropriate to the nature of the objection; and,
(b) Information necessary to allow the Medicaid Beneficiary to request
a Medicaid Fair Hearing, if appropriate, including the contact
inform.ation necessary to pursue a Medicaid Fair Hearing (see
Medicaid Fair Hearing System Section).
(3) Provide the CTC with a report detailing the total number of Complaints
received, pursuant to Reporting Requirements of this contract; and,
(4) The PROVIDER shall not take any punitive action against a physician or
other Health Care Provider who files a Complaint on behalf of a Medicaid
Beneficiary, or supports a Medicaid Beneficiary's Complaint.
b. Filing Requirements
(1) The Medicaid Beneficiary or a representative of the Medicaid Beneficiary,
acting on behalf of the Medicaid Beneficiary and with the Medicaid
Beneficiary's written consent must file a Complaint within fifteen (15)
Calendar Days after the date of occurrence that initiated the Complaint.
(2) The Medicaid Beneficiary or his/her representative may file a Complaint
either orally or in writing. The Medicaid Beneficiary or his/her
representative may follow up an oral-request with a written request,
however the timeframe for resolution begins the date the PROVIDER
receives the oral request.
C. The Grievance Process
1 A Medicaid Beneficiary may file a Grievance, or a representative of the Medicaid
Beneficiary, acting on behalf of the Medicaid Beneficiary and with the Medicaid
Beneficiary's written consent, may file a Grievance.
2. General Duties
a. The PROVIDER must:
(1) Resolve each Grievance within ninety (90) Calendar Days from the day
the PROVIDER received the initial Grievance request, be it oral or in
writi ng;
(2) Notify the Medicaid Beneficiary, in writing, within thirty (30) Calendar
Days of the resolution of the Grievance. The notice of disposition shall
include the results and date of the resolution of the Grievance, and for
decisions not wholly in the Medicaid Beneficiary's favor, the notice of
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disposition shall include:
(a) Notice of the right to request a Medicaid Fair Hearing, if
applicable; and,
(b) Information necessary to allow the Medicaid Beneficiary to request
a Medicaid Fair Hearing, including the contact information
necessary to pursue a Medicaid Fair Hearing (see Medicaid Fair
Hearing System Section, below);
(3) Provide the erc with a copy of the written notice of disposition upon
request;
(4) The PROVIDER shall not take any punitive action against a physician or
other health care provider who files a Grievance on behalf of a Medicaid
Beneficiary, or supports a Medicaid Beneficiary's Grievance; and,
(5) Provide the erc with a report detailing the total number of Grievances
received, pursuant to the Reporting Requirements Section of this
Contract.
b. The PROVIDER may extend the Grievance resolution time frame by up to
fourteen (14) Calendar Days if the Medicaid Beneficiary requests an extension, or
the PROVIDER documents that there is a need for additional information and
that the delay is in the Medicaid Beneficiary's best interest.
(1) If the PROVIDER requests the extension, the PROVIDER must give the
Medicaid Beneficiary written notice of the reason 'for the delay.
c. Filing Requirements
(1) The Medicaid -Beneficiary or provider must file a Grievance within one (1)
year after the date of occurrence that initiated the Grievance.
(2) The Medicaid' Beneficiary or provider may file a Grievance. either orally or
in writing. The Medicaid Beneficiary may follow up an oral request with a
written request, however the timeframe for resolution begins the date the
PROVIDER receives the oral request.
D. The Appeal Process
1 A Medicaid Beneficiary may file an Appeal, or a representative of the Medicaid
Beneficiary, acting on behalf of the Medicaid Beneficiary and with the Medicaid
Beneficiary's written consent, may file an Appeal.
2 General Duties
a. The PROVIDER shall:
(1) Confirm in writing all oral inquiries seeking an Appeal, unless the
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Medicaid Benefi~iary or provider requests an expedited resolution;
(2) If the resolution is in favor of the Medicaid Beneficiary, provide the
services as quickly as the Medicaid Beneficiary's health condition requires;
(3) Provide the Medicaid Beneficiary or provider with a reasonable
opportunity to present evidence and allegations of fact or law, in person
and/or in writing;
(4) Allow the Medicaid Beneficiary, and/or the Medicaid Beneficiary's
representative, an opportunity, before and during the Appeal process, to
examine the Medicaid Beneficiary's case file, including all documents and
records;
(5) . Consider the Medicaid Beneficiary, the Medicaid Beneficiary's
representative or the representative of a deceased Medicaid Beneficiary's
estate as parties to the Appeal;
(6) Continue the Medicaid Beneficiary's Transportation Services if:
(a) The Medicaid Beneficiary files the Appeal in a timely manner,
meaning on or before the later of the following:
(i) Within ten (10) Business Days of the date on the notice of
Action (add five [5] Business Days if the notice is sent via
Surface Mail); or,
(ii) The intended effective date of the PROVIDER's proposed
Action.
(b) The Appeal involves the termination, suspension, or reduction of a
previously authorized Transportation service;
(c) The Transportation was for a Medicaid compensable service
ordered;
(d) The authorization period has not expired; and/or,
(e) The Medicaid Beneficiary requests extension of Transportation
Services.
(7) Provide written notice of the resolution of the Appeal, including the
results and date of the resolution within two (2) Business Days after the
resolution. For decisions not wholly in the Medicaid Beneficiary's favor,
the notice of resolution shall include:
(a) Notice of the right to request a Medicaid Fair Hearing;
(b) Information about how to request a Medicaid Fair Hearing,
including the DCF address necessary for pursuing a Medicaid Fair
Hearing, as set forth in Medicaid Fair Hearing System Section,
below; .
(c) Notice of the right to 'continue to receive Transportation Services
pending a Medicaid Fair Hearing;
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(d) Information about how to request the continuation of
Transportation Services; and
(e) Notice that if the PROVIDER's Action is upheld in a Medicaid Fair
Hearing, the Medicaid Beneficiary may be liable for the cost of any
continued Transportation Services.
(8) Provide the erc with a copy of the written notice of disposition upon
request;
(9) Transportation Providers shall not take any punitive action against a
physician or other health care provider who files an Appeal on behalf of a
Medicaid Beneficiary or supports a Medicaid Beneficiary's Appeal; and,
(10) Provide the ere with a report detailing the total number of Appeals
received, pursuant to Reporting Requirements of this Contract.
b. The PROVIDER shall continue or reinstate the Medicaid Beneficiary's
Transportation Services while the Appeal is pending, the PROVIDER must
continue providing the Transportation Services until one (1) of the following
occurs:
(1) The Medicaid Beneficiary withdraws the Appeal;
(2) Ten (10) Business Days pass from the date of the PROVIDER's notice of
resolution of the Appeal if the resolution is adverse to the Medicaid
Beneficiary and if the Medicaid Beneficiary has not requested a Medicaid
Fair Hearing with continuation of Transportation Services until a Medicaid
Fair Hearing decision is reached;
(3) The Medicaid Fair Hearing panel's decision is adverse to the Medicaid
Beneficiary; or,
(4) The authorization to provide services expires, or the Medicaid Beneficiary
meets the authorized service limits.
c. If the final resolution of the Appeal is adverse to the Medicaid Beneficiary, the
PROVIDER may recover the costs of the services furnished from the Medicaid
Beneficiary while the Appeal was pending, to the extent that the PROVIDER
furnished the services solely because of the requirements of this Section.
d. If the PROVIDER did not furnish services while the Appeal was pending and the
Appeal panel reverses the PROVIDER's decision to deny, limit or delay services,
the PROVIDER must authorize or provide the disputed services promptly and as
quickly as the Medicaid Beneficiary's health condition requires.
e. If the. PROVIDER furnished services while the Appeal was pending and the
Appeal panel reverses the PROVIDER's decision to deny, limit or delay services,
the PROVIDER must pay for disputed services in accordance with State policy
and regulations.
3. Filing Requirements
a. The Medicaid Beneficiary or his/her representative must file an Appeal within
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thirty (30) Calendar Days of receipt of the notice of the PROVIDER's Action.
b. The Medicaid Beneficiary may file an Appeal either orally or in writing. If the
filing is oral, the Medicaid Beneficiary must also. file a written, signed Appeal
within thirty (30) Calendar Days of the oral filing. The PROVIDER shall notify the
requesting party that it must file the written request within ten (10) Business
Days after receipt of the oral request. For oral filings, time frames for resolution
of the Appeal begin on the date the PROVIDER receives the oral filing.
c. The PROVIDER shall resolve each Appeal within State-established time frames
not to exceed forty-five (45) Calendar Days from the day the PROVIDER received
the initial Appeal request, whether oral or in writing.
d. If the resolution is in favor of the Medicaid Beneficiary, the PROVIDER shall
provide the services as quickly as the Medicaid Beneficiary's health condition
requires.
e. The PROVIDER may extend the resolution time frames by up to fourteen (14)
Calendar Days if the Medicaid Beneficiary requests an extension, or the
PROVIDER documents that there is a need for additional information and that
the delay is in the Medicaid Beneficiary's best interest.
(1) If the PROVIDER requests the extension, the PROVIDER must give the
Medicaid Beneficiary written notice of the reason for the delay.
(2) The PROVIDER must provide written notice of the extension to the
Medicaid Beneficiary within five (5) Business Days of determining the
need for an extension.
4. Expedited Process
a. The PROVIDER shall establish and maintain an expedited review process for
Appeals when the PROVIDER determines, the Medicaid Beneficiary requests or
the provider indicates (in making. the ,request 'on the Medicaid Beneficiary's behalf
or supporting the Medicaid Beneficiary's request) that taking the time for a
standard resolution could seriously jeopardize the Medicaid Beneficiary's life,
health or ability to attain, maintain or regain maximum function.
b. The Medicaid Beneficiary may file an expedited Appeal either orally or in writing.
No additional written follow-up on the part of the Medicaid Beneficiary is required
for an oral request for an expedited Appeal.
c. The PROVIDER must:
(1) Inform the Medicaid Beneficiary of the limited time available for the
Medicaid Beneficiary to present evidence and allegations of fact or law, in
person and in writing;
(2) Resolve each expedited Appeal and provide notice to the Medicaid
Beneficiary, as quickly as the Medicaid Beneficiary's health condition
requires, within State established time frames not to exceed seventy-two
(72) hours after the Recipient/Subcontractor receives the Appeal request,
whether the Appeal was made orally or in writing;
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(3) Provide written notice of the resolution in accordance with the Appeal
Process Section, of the expedited Appeal to the Medicaid Beneficiary;
(4) Make reasonable efforts to provide oral notice of disposition to the
Medicaid Beneficiary immediately after the Appeal panel renders a
decision; and,
(5) The PROVIDER shall take any punitive action ~gainst a physician or other
health care provider who requests an expedited resolution on the
Medicaid Beneficiary's behalf or supports a Medicaid Beneficiary's request
for expedited resolution of an Appeal.
a. If the PROVIDER denies a request for an expedited resolution of an Appeal, the
PROVIDER must:
(1) Transfer the Appeal to the standard time frame of no longer than forty-
five (45) Calendar Days from the day the Recipient/Subcontractor
received the request for Appeal (with a possible fourteen [14] day
extension) ;
(2) Make all reasonable efforts to provide immediate oral notification of the
Recipient's/Subcontractor's denial for expedited resolution of the Appeal;
(3) Provide. written notice of the denial of the expedited Appeal within two
(2) Calendar Days; and,
(4) Fulfill all requirements set forth in the Appeal Process Section above.
E. Medicaid Fair Hearing System
1. As set forth in Ru'e 65-2.042, FAC, the Recipient's/Subcontractor's Grievance Procedure
and Appeal and Grievance processes shall state that the Medicaid Beneficiary has the
right to request a Medicaid Fair Hearing, in addition to, and at the same ,time as,
pursuing resolution through the Recipient's/Subcontractor's Grievance and Appeal
processes.
a. A physician or other health care provider must have a Medicaid Beneficiary's
written consent before requesting a Medicaid Fair Hearing on behalf of a
Medicaid Beneficiary.
b. The parties to a Medicaid Fair Hearing include the PROVIDER, as well as the
Medicaid Beneficiary, his/her representative or the representative of a deceased
Medicaid Beneficiary's estate.
2. Filing Requirements
a. The Medicaid Beneficiary may request a Medicaid Fair Hearing within ninety (90)
days of the date of the notice of the PROVIDER's resolution of the Medicaid
Beneficiary's Grievance/Appeal by contacting DCF at:
The Office of Appeal Hearings1317 Winewood Boulevard, Building 5, Room 203
Tallahassee, Florida 32399-0700
3. General Duties
a. The PROVIDER must:
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(1) Continue the Medicaid Beneficiary's Transportation Services while the
Medicaid Fair Hearing is pending if:
(a) The Medicaid Beneficiary filed for the Medicaid Fair Hearing in a
timely manner, meaning on or before the later of the following:
(i) Within ten (10) Business Days of the date on the notice of
Action (add five [5] Business Days if the notice is sent via
Surface Mail);
(ii) The intended effective date of the PROVIDER's proposed
Action.
(b) The Medicaid Fair Hearing involves the termination, suspension, or
reduction of a previously authorized course of treatment;
(c) The authorization period has not expired; and/or,
(d) The Medicaid Beneficiary requests extension of Transportation
Services.
(2) The PROVIDER shall take any punitive action against a physician or other
health care provider who requests a Medicaid Fair Hearing on a Medicaid
Beneficiary's behalf or supports a Medicaid Beneficiary's request for a
Medicaid Fair Hearing.
b. If the PROVIDER continues or reinstates Medicaid Beneficiary Transportation
Services while the Medicaid Fair Hearing is pending, the PROVIDER must
continue said Transportation Services until one (1) of the following occurs:
(1) The Medicaid Beneficiary withdraws the request for a Medicaid Fair
Hearing;
(2) Ten (10) Business Days pass from the date of the PROVIDER's notice of
resolution of the Appeal if the resolution is adverse to the Medicaid
Beneficiary and the Medicaid Beneficiary has not requested a Medicaid
Fair Hearing with continuation of Transportation Services until a Medicaid
Fair Hearing decision is reached (add five [5] Business Days if the
Recipient/Subcontractor sends the notice of Action by Surface Mail);
(3) The Medicaid Fair Hearing officer renders a decision that is adverse to the
Medicaid Beneficiary; and/or,
(4) The Medicaid Beneficiary's authorization expires or the Medicaid
Beneficiary reaches his/her authorized service limits.
1 If the final resolution of the Medicaid Fair Hearing is adverse to the Medicaid Beneficiary,
the PROVIDER may recover the costs of the services furnished while the Medicaid Fair
Hearing was pending, to the extent that the PROVIDER furnished said services solely
because of the requirements of this Section.
2 If the PROVIDER did not furnish services while the Medicaid Fair Hearing was pending,
and the Medicaid Fair Hearing resolution reverses the PROVIDER's decision to deny, limit
or delay services, the PROVIDER must authorize or provide the disputed services as
quickly as the Medicaid Beneficiary's health condition requires.
3 If the PROVIDER did furnish services while the Medicaid Fair Hearing was pending, and
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the Medicaid Fair Hearing resolution reverses the PROVIDER's decision to deny, limit or
delay services, the PROVIDER must pay for the disputed services in accordance with
State policy and regulations.
Type Time Frame to File Provide Time Frame to Extension Time Frame to Next Step
Transportation Resolve Time Frame Send (if any)
Services During Notification of
Review Resolution
Complaint Ninety (90) Calendar Yes Fifteen (15) Ten (10) Five (5) File a
Days From the Date of Business Days Business Days Business Days Grievance
the Incident That From the Date
Precipitated the of the
Complaint Complaint
Grievance Ninety (90) Calendar Yes Ninety (90) Fourteen (14) Thirty (30) Medicaid Fair
Days From the Date of Calendar Days Calendar Days Calendar Days Hearing
the Action that from the Date
Precipitated of the
Resolution of
the Grievance
VIII. ADMINISTRATION AND MANAGEMENT
A. General Provisions
1 The PROVIDER's governing body shall set forth policy and has overall responsibility for
the organization of the PROVIDER. The PROVIDER shall be responsible for the
administration and management of all aspects of this Agreement, including all
Subcontracts, employees, agents, and services performed by anyone acting for or on
behalf of the PROVIDER. The PROVIDER shall have a centralized executive
administration, which shall serve as the contact point for the erc, except as otherwise
specified in this Agreement.
2 The PROVIDER shall be responsible for the administration and management of all
aspects of this Agreement, such as, but not limited to the delivery of Transportation
Services. If the PROVIDER Subcontracts any of its administrative and management
duties under this Agreement, the erc shall hold the PROVIDER responsible for ensuring
that the Subcontractor(s) maintain the same standards as the PROVIDER in
administerin"g and managing all aspects of the Subcontract. If the Subcontractor fails to
maintain the same administration and management standards as the PROVIDER, the
ere shall sanction the PROVIDER in accordance with this Contract.
3 The PROVIDER shall not provide incentives to its Subcontractors to deny, limit, or
discontinue Transportation Services to any Medicaid Beneficiary inappropriately.
B. Staffing
1. The PROVIDER shall maintain an adequate and competent staff so as to enable the
PROVIDER to timely perform under this Agreement
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C. Subcontract Requirements
1. The PROVIDER shall comply with all CTC procedures for Subcontracts review and
approval submission.
a. All Subcontracts must comply with 42 CFR 438.230.
b. The PROVIDER shall be eligible for participation in the Medicaid program. If
Medicaid involuntarily, terminated a PROVIDER from the Florida Medicaid
program, other than for purposes of inactivity, that PROVIDER is not an eligible
Medicaid provider.
c. The PROVIDER shall not employ or contract with individuals on the State or
federal exclusions list available from the Department of Management Services'
List of Excluded Vendors and the federal List of Excluded Individuals and Entities.
d. No Subcontract that the PROVIDER enters into with respect to performance
under this Agreement shall in any way relieve the PROVIDER of any
responsibility for the. provision of Transportation Services and other duties set
forth in this Agreement. The PROVIDER shall assure that Transportation
Providers perform all services and tasks related to the Subcontract in accordance
with the terms of this Agreement.
e. The PROVIDER shall include its Grievance System in its Subcontracts to ensure
uniformity of its Grievance System statewide.
2. All Subcontracts and amendments executed by the PROVIDER must be in writing and
signed by the Recipient and the Subcontractor. All model and executed Subcontracts
and amendments entered into as a result of this Agreement shall meet the following
requirements:
a. Prohibit the Subcontractor from seeking payment from the Medicaid Beneficiary
for any Covered Services provided to the Medicaid Beneficiary within the terms of
the Agreement.
b. Require the Subcontractor to look solely to the PROVIDER for compensation for
services rendered, with the exception of co-payments, pursuant to the State
Medicaid Plan and the Non-Emergency Transportation Services Coverage &
Limitations Handbook (Handbook).
c. The Subcontract shall not contain an incentive plan that, in any way, acts as an
inducement to reduce or limit Transportation Services to a Medicaid Beneficiary
inappropriately.
d. Specify that any contracts, agreements, or Subcontracts entered into by the
Subcontractor for the purposes of carrying out any aspect of this Agreement
must include assurances that the individuals who are signing the contract,
agreement or Subcontract are so authorized and that it includes all the
requirements of this Agreement.
e. Require the Subcontractor to cooperate with the PROVIDER's Grievance and
Appeal policies and procedures and provide for monitoring and oversight,
including monitoring of Transportation, Services rendered to Medicaid
Beneficiaries, by the PROVIDER and for the Subcontractor to provide proof
annually, or at the request of the PROVIDER, the CTC, or its agent, that
f. Not prohibit a Subcontractor from advocating on behalf of a Medicaid Beneficiary
in any Grievance System or UM process, or individual authorization process to
obtain necessary Transportation Services.
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g. Prohibit discrimination with respect to participation, reimbursement, or
indemnification of any Subcontractor who is acting within the scope of his or her
license or Certification under applicable State law, solely on the basis of such
license or Certification. The PROVIDER should not construe this provision as a
willing provider law, as it does not prohibit the PROVIDER from limiting provider
participation to the extent necessary to meet the needs of the Medicaid
Beneficiaries. This provision does not interfere with measures established by the
PROVIDER designed to maintain quality and control costs
h. Prohibit discrimination against Subcontractors serving Medicaid Beneficiaries in
high-risk populations or Subcontractors that specialize in conditions requiring
costly transport. .
i. Require the Subcontractor to maintain an adequate record system for recording
services, charges, dates and all other commonly accepted information elements
for services rendered to the Recipient.
j. Require that the Subcontractor maintain records related to this Agreement for a
period not less than five (5) years from the close of the Agreement, and retained
further if the records are under review or audit until the review or audit is
complete
k. Specify that the United States Department of Health & Human Services (DHHS)
and the Agency or its Agents shall have the right to inspect, evaluate, and audit
any records pertinent to the Agreement, including, but not limited to, the
following:
(1) Pertinent books;
(2) Financial records; and,
(3) Documents, papers, and records of any Transportation Provider involving
financial transactions
I. SpecifY Covered Services and populations that the Subcontractor will serve under
the Subcontract.
m. Require that Subcontractors comply with the Recipients Cultural Competency
Plan
n. Require that any materials related to this Agreement that the Subcontractor
distributes are submitted to the CTC for written approval before use
o. Provide for submission of all reports and information required by the Recipient.
p. Require Subcontractors to submit notice of withdrawal from the Recipient's
Transportation Provider network at least. ninety (90) Calendar Days prior to the
effective date of such withdrawal.
q. Require an Subcontractors to notify the Recipient in the event of a lapse in
general liability or other applicable insurance.
r. Require safeguarding of information according to 42 CFR, Part 438.224. about
Medicaid Beneficiaries
s. Require compliance with HIPAA privacy and security provisions
t~ Require an exculpatory clause, which survives termination of the Subcontract,
including breach of Subcontract due to Insolvency, that assures that the
Subcontractor's creditors 'cannot hold either Medicaid Beneficiaries or the AHCA
or the CTC liable for any debts of the Subcontractors
u. Contain a clause indemnifying, defending, and holding the AHCA, the CTC and
the PROVIDER's Medicaid Beneficiaries harmless from and against all claims,
damages, causes of action, costs or expense, including court costs and
reasonable attorney fees, to the extent proximately caused by any negligent act
or other wrongful conduct arising from the Subcontract:
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(1) This clause must survive the termination of the Subcontract, including
breach due to Insolvency; and,
(2) The CTD and/or AHCA may waive this requirement for itself, but not
Medicaid Beneficiaries, for damages in excess of the statutory cap on
damages for public entities if the Subcontractor is a public health entity
with statutory immunity (the AHCA must approve all such waivers in
writing).
v. Where applicable, require that all Subcontractors secure and maintain, during the
life of the Subcontract, worker's compensation insurance (complying with the
Florida's Worker's Compensation Law) for all of its employees/independent
contractors connected with the work under this Agreement unless such
employees/independent contractors are covered by the protection afforded by
the Recipient or Subcontractor.
w. Make provisions for a waiver of those terms of the Subcontract, which, as they
pertain to Medicaid Beneficiaries, are in conflict with the specifications of this
Agreement.
x. Contain no provision that in any way prohibits or restricts the Subcontractor from
entering into a contract with any other Vendor.
'y. Contain no provision requiring the Subcontractor to contract for more than one
(1) transportation agreement or otherwise be excluded.
z. Require Subcontractors to cooperate fully in any investigation by the AHCA or the
Attorney General's Medicaid Fraud Control Unit (MFCU), or any subsequent 'Iegal
action that may result from such an investigation.
aa. Provide that the CTC, AHCA and DHHS may evaluate, through inspection or other
means, the quality, appropriateness, and timeliness of the Transportation
Services performed.
bb. Provide the PROVIDER and the CTC with the ability to monitor the Subcontractor
to ensure that all Transportation Providers are properly Licensed and inspected
pursuant to State, county, and local statute and regulations.
cc. Provide the CTC and PROVIDER with the ability to monitor and oversee all
Transportation Services provided by Subcontractors to Medicaid Beneficiaries.
dd. Identification of conditions and method of payment:
(1) The PROVIDER agrees to make payment to all Subcontractors pursuant
to all State and federal laws, rules, and regulations, specifically, Section
641.3155, F.S., 42 CFR 447.46, and 42 CFR 447.45(d)(2), (d)(3), (d)(S),
and (d)(6); and,
(2) Provide for prompt submission by the Subcontractor of all information
and encounter data needed to make payment.
ee. Specify that if the Subcontractor delegates or Subcontracts any functions of the
PROVIDER, that the Subcontract or delegation includes all requirements of this
Agreement.
ff. Provide for revoking a previously Subcontracted delegation, or imposing other
sanctions, if the Subcontractor's performance is inadequate.
3. PROVIDER{Transportation Provider Termination
a. The PROVIDER shall comply with all State and federal laws regarding
Transportation Provider termination. In its Transportation Provider Agreements,
the Recipient shall:
(1) In addition to any other right to terminate the PROVIDER Agreement, and
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not withstanding any other provision of this Contract, the CTC may
request immediate termination of a PROVIDER Agreement if, as
determined by the CTC, a PROVIDER fails to abide by the terms and
conditions of the PROVIDER Agreement, or in the sole discretion of the
CTC, the PROVIDER fails to come into compliance with the PROVIDER
contract within fifteen (15) Calendar Days after receipt of notice from the
CTC specifying such failure and requesting such PROVIDER abide by the
terms and conditions thereof; and,
(2) If the CTC terminates a PROVIDER pursuant to any provision of the
PROVIDER Contract, the PROVIDER shall use the applicable appeals
procedures outlined in the PROVIDER Contract. There is no additional or
separate right of appeal to the AHCA or the CTC as a result of the erc's
act of terminating, or decision to terminate any PROVIDER under this
Contract.
(3) The CTC shall provide sixty (60) Calendar Days' advance written notice to
the PROVIDER before canceling, without cause, a PROVIDER Contract
D. Transportation Provider Services
1. General Provisions
a. The PROVIDER shall provide sufficient information to all Transportation Providers
in order to operate in full compliance with this Contract and all applicable federal,
State, and local laws and regulations.
b. The PROVIDER shall monitor each Transportation Provider to ensure that each
Transportation Provider complies with the requirements of this Contract and all
applicable federal, State, and local laws and regulations and shall take or require
corrective actions to ensure compliance with such requirements.
c. The Transportation Provider Agreements shall incorporate all provisions of the
PROVIDERs agreement with the CTC (Subcontract), unless otherwise set forth
below.
2. Transportation Provider Handbooks
a. The CTC shall develop and issue a Transportation Provider Handbook. All
Transportation Provider Handbooks and bulletins shall be in compliance with
State a.nd federal laws. The Transportation Provider Handbook shall serve as a
source of information regarding Covered Services, policies and procedures,
statutes, regulations, telephone access, and special requirements to ensure that
all contract requirements are met. At a minimum, the Transportation Provider
Handbook shall include the following information:
(1) Description of the Non-Emergency Transportation program;
(2) Covered Services;
(3) Information about the Grievance System, the timeframes and
requirements, the availability of assistance in filing, the toll-free numbers
and the Medicaid Beneficiary's right to request continuation of
Transportation Services while utilizing the Grievance System;
(4) Routine, Hospital/facility discharges, Urgent Care, Emergency
room/faCility discharges, and will call policies and procedures;
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(5) The Cultural Competency Plan;
(6) Medicaid Beneficiary rights and responsibilities (see 42 CFR 438.100 for
guidance as to a Medicaid Beneficiary's rights and responsibilities); and,
(7) Other Transportation Provider responsibilities.
b. Bulletins shall be disseminated as needed to incorporate any changes or updates
to the Transportation Provider Handbook.
3. Education and Training
a. PROVIDERs shall attend and/or participate in training and educational workshops
when scheduled by the erc.
E. Medicaid Beneficiary Eligibility Records Requirements
1. The PROVIDER shall maintain records, either electronically or by hard copy, for each
Medicaid Beneficiary in accordance with this Section.
a. The PROVIDER's Medicaid Beneficiary eligibility records must include all
Encounter Data elements as set forth in the Encounter Data Section. At a
minimum, the PROVIDER's Medicaid Beneficiary eligibility records must include
the following:
(1) Each record must be legible and maintained in detail;
(2) All record entries must be dated;
(3) All records must reflect the primary language spoken by the Medicaid
Beneficiary and any translation needs of the Medicaid Beneficiary;
(4) All records must identify Medicaid Beneficiaries needing communication
assistance in the delivery of Transportation Services;
(5) All records must show whether the Medicaid Beneficiary has any specific
needs that require special equipment or services (e.g., dementia, uses a
walker, etc.); and,
(6) All records must show whether the Medicaid Beneficiary requires a
medical Attendant/Escort or assistance in accessing medical services
(e.g., door-to-door delivery, etc.).
b. Confidentiality of Medicaid Beneficiary Eligibility Records
(1) The PROVIDER shall ensure the confidentiality of Medicaid Beneficiary
eligibility records in accordance with 42 CFR, Part 431, Subpart F and the
Privacy and Security provisions of the Health Insurance Portability and
Accountability Act (HIPAA).
F. Invoice Payment
1 An invoice is considered received when the erc receives the invoice in its Offices.
2 The erc has eleven (11) business days to inspect and approve goods and services. If
payment is not available within forty (40) calendar days, measured from the latter of the
date the invoice is received or the goods or services are received, inspected and
approved, a separate interest penalty set by the Comptroller pursuant to Section 55.03,
F. S., will be due and payable in addition to the invoice amount. To obtain the
applicable interest rate, please contact the erc's Fiscal Section at (850) 410-5700.
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Invoices returned to a PROVIDER due to preparation errors will result in a payment
delay. Invoice payment requirements do not start until a properly completed invoice is
provided to the crC. A Vendor Ombudsman, whose duties include acting as an
advocate for Vendors who may be experiencing problems in obtaining timely payment(s)
from a State Agency, may be contacted at (850) 410-9724 or by calli-ng the State
Comptroller's Hotline, 1-800-848-3792.
G. Encounter Data
1. The PROVIDER shall collect and submit Encounter Data to the crC. The PROVIDER shall
have a comprehensive automated and integrated Encounter Data system that is capable
of meeting the requirements as defined by the crD. The required data elements are
provided in Attachment 3.
The attach chart is the Draft Batch File Layout for the new Medicaid system. There will
be an additional one alpha character identifier for any record that contains a Social
Security Number consisting of all 9's (the only acceptable entry other than a valid SSN),
that's not shown in this File Layout. This field must be occupied with either an I for
Infant or A for Alien (not case-sensitive) if the value is all 9's (999-99-9999). In the case
of a valid SSN, this field will be left blank. The exact File Layout, including the location of
this new data element, will be provided by the crc as soon as it is finalized.
2. The PROVIDER is responsible for errors or noncompliance resulting from its own actions
or the actions of an agent authorized to act on its behalf. The PROVIDER shall resolve
any errors or noncompliance and resubmit the Encounter Data.
a. The crc shall monitor the PROVIDER's submissions and provide error reports for
the PROVIDER to resolve and resubmit.
1 The PROVIDER shall implement review procedures to validate their own
Encounter Data.
2 The PROVIDER will designate sufficient information technology and
staffing resources to perform these functions as set forth in this
Agreement.
3 The PROVIDER shall have a unique Florida Medicaid provider
identification number.
4 The PROVIDER must attend and/or participate in training provided by the
crc and/or AHCA regarding:
3. All Encounter Data from submission and resubmission shall be:
a. Complete
(1) All Trips shall be entered for the reported period.
(2) All required data fields shall be populated.
b. Accurate
(1) One hundred percent (1000/0) of all fields shall contain valid values.
(2) The PROVIDER shall input the fully allocated Cost in the "trip cost" field
based on the crc rate methodology.
c. Timely
(1) The PROVIDER shall submit Encounter Data no later than thirty (30)
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Calendar Days after the end of the reporting month.
(2) The PROVIDER shall submit all corrected Encounter Data within ninety
(90) Calendar Days after the end of the reporting month
. 4 The PROVIDER shall cooperate with CTC staff and its authorized representatives
regarding onsite visits to evaluate the PROVIDER's MEDS operations, which include
providing access to Transportation Records and administrative records for review. The
PROVIDER shall participate in CTC and/or AHCA sponsored workgroups directed at
continuous improvements in Encounter Data quality and operations.
S. The CTC and CTD will monitor and track the quality of the PROVIDER's Encounter Data
submissions and provide feedback to the PROVIDER and/or CTC pursuant to the
schedule set forth below.
a. The CTC shall use seventy-five percent (750/0) accuracy as the starting point or
benchmark for determining quality of the Encounter Data submissions.
b. For purposes of this section, quality means that the Encounter Data for the
service rendered conforms to the terms and conditions of this Agreement.
6. If the PROVIDER's Encounter Data reporting is not acceptable, the CTC shall require the
PROVIDER to submit a Corrective Action Plan (CAP)~ If the PROVIDER fails to provide a
CAP, or to implement an approved CAP, within the time specified by the CTC, the erc
shall sanction the PROVIDER, in accordance with the Contract. When considering
whether to impose sanctions, the CTC may take into account the PROVIDER's
cumulative performance on all MEDS activities.
H. Fraud Prevention
1 The PROVIDER shall establish functions and activities governing program integrity in
order to reduce the incidence of Fraud and Abuse and shall comply with all State and
federal program integrity requirements.
2 The Recipient shall have internal controls and policies and procedures in place that are
designed to prevent, detect, and report known or suspected Fraud and Abuse activities.
3 The Recipient shall cooperate fully in any investigation by the AHCA, MPI, MFCU, or any
subsequent legal action that may result from such an investigation.
4. Ensure that the Recipient does not retaliate against any individual who reports Violations
of the Recipient's Fraud and Abuse policies and procedures or suspected Fraud and
Abuse.
IX. INFORMAnON MANAGEMENT AND SYSTEMS
A. General Provisions
1 Systems Functions - The PROVIOER shall have Information Management processes and
Information Systems that enable it to meet CTC, CTD, AHCA and federal reporting
requirements and other Agreement requirements and that are in compliance with this
Agreement and all applicable State and federal laws, rules and regulations, including
HIPAA.
2 Systems Capacity - The PROVIDER's Systems shall possess capacity sufficient to handle
the workload projected for the begin date of operations and will be scalable and flexible
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so they can be adapted as needed, within negotiated timeframes, in response to
changes in Agreement requirements, etc.
3 Participation in Information Systems Work Groups/Committees - The PROVIDER shall
meet as requested by the CTC, to coordinate activities and develop cohesive Systems
strategies across PROVIDERs and agencies.
4 Sanctions - The PROVIDER shall maintain all Systems and submit all reports as set forth
in this Section and the Reporting Requirements Section of this Contract. If the
PROVID.ER fails to maintain its Systems or submit all reports asset forth, the CTC shall
sanction the PROVIDER in accordance with this Contract.
B. Data and Document Management Requirements
1. Adherence to Data and Document Reporting Requirements
a. The PROVIDER's Systems shall conform to HIPAA standards for data and
document management that are currently under development within one
hundred twenty (120) Calendar Days of the Agreement's effective date or, if
earlier, the date stipulated by CMS or the AHCA.
2. Information Retention - The PROVIDER shall maintain Information in its Systems in
electronic form for three (3) years in live Systems and, for audit and reporting purposes,
for five (5) years in live and/or archival Systems.
. 3. Information Ownership - The CTD maintains ownership over all Information, whether
data, documents, or reports that contain or make references to said Information
involving or arising out of this Agreement.
a. If the PROVIDER is required to provide documentation pursuant to a public
records request, the PROVIDER shall redact any and all personal health
information, in compliance with HIPAA and all other applicable federal and state
laws and regulations.
b. If the PROVIDER wishes to publish a report, info-rmation, or commentary that
includes data drawn from the Medicaid population, the erD and/or the AHCA
must first give written approval to the PROVIDER's interpretation of all data
before the PROVIDER can publish said report, information, or commentary.
(1) In order to expedite approval of any report, information, or commentary
that uses data drawn from the Medicaid population, the PROVIDER must
include with its written request for approval all documentation, statistics,
tables, graphs, and details that give rise to the PROVIDER's interpretation
and the basis upon which the Recipient uses the data to support its
interpretation.
C. System and Data Integration Requirements
1. Data and Report Validity and Completeness
a. The PROVIDER shall institute processes to ensure that the data is valid and
complete; including reports submitted to the erc pu~uant to the Reporting
Requirements of this contract. At its discretion, the erc will conduct general data
validity and completeness audits using industry-accepted statistical sampling
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methods. The erc shall audit specific data elements including, but not limited to:
Medicaid Beneficiary ID, date of service, category and sub category (if
applicable) of service, procedure codes, revenue codes, date of claim processing,
and (if and when applicable) date of claim payment. The erc shall also review
and verify control totals.
2. Data Exchange in Support of the erc's Program Integrity and Compliance Functions
a. The PROVIDER's System(s) shall be capable of generating files in the prescribed
formats for upload into erc Systems used specifically for program integrity and
compliance purposes.
D. Systems Availability, Performance, and Problem Management Requirements
1. Availability of Critical Systems Functions
a. The PROVIDER shall ensure that critical Systems functions available to Medicaid
Beneficiaries and Transportation Providers, functions that if unavailable would
have an immediate detrimental impact on Medicaid Beneficiaries and
Transportation Providers, are available twenty-four (24) hours a day, seven (7)
days a week, except during periods of scheduled System Unavailability agreed
upon by the erc and the PROVIDER. Unavailability caused by events outside of a
PROVIDER's Span of Control is outside the scope of this requirement. The
PROVIDER shall make the erc aware of the nature and availability of these
functions prior to extending access to these functions to Medicaid Beneficiaries
and/or Transportation Providers.
2. Availability of Data Exchange Functions
a. The PROVIDER shall ensure that the Systems and processes within its Span of
Control associated with its data exchanges with the erc and/or its Agent(s) are
available and operational according to specifications and the data exchange
schedule.
3. Problem Notification
a. Upon discovery of any problem within its Span of Control that may jeopardize, or
is jeopardizing, the availability and performance of Systems functions and the
availability of information in said Systems, including any problems impacting
scheduled exchanges of data between the PROVIDER and the erc and/or its
Agent(s), the PROVIDER shall notify the erc's Project Manager via phone, fax
and/or electronic mail within fifteen (15) minutes of such discovery. In its
notification, the PROVIDER shall explain in detail the impact to critical path
processes such as transportation coordination and claims submission processes.
b. The PROVIDER shall provide to appropriate ere staff, or its Agent's staff,
information on System Unavailability events, as well as status updates on
problem resolution. At a minimum, the PROVIDER shall provide these updates on
an hourly basis via electronj-c mail or telephone (if electronic mail is unavailable
due to the System Unavailability).
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4. Recovery from Unscheduled System Unavailability
a. Unscheduled System Unavailability caused by the failure of Systems and
telecommunications technologies within the PROVIDER's Span of Control must be
resolved, and the restoration of services implemented, within forty-eight (48)
hours of the official declaration of System Unavailability.
5. Exceptions to System Availability Requirement
a. The PROVIDER shall not be responsible for the availability and performance of
Systems and information technology (IT) infrastructure technologies outside of
the PROVIDER's Span of Control.
E. System Testing and Change Management Requirements
1. Notification and Discussion of Potential System Changes
a. The PROVIDER shall notify the CTC Project Manager of the following changes to
Systems within its Span of Control within at least ninety (90) Calendar Days of
the projected date of the change; if so directed by the CTC, the PROVIDER shall
discuss the proposed .change with applicable CTC staff: (1) software release
updates of core transaction Systems: claims processing, eligibility and Enrollment
processing, Service Authorization management, Transportation Provider
enrollment and. data management; (2) conversions of core transaction
management Systems.
2. Response to CTC Reports of Systems Problems not Resulting in System Unavailability
a. The PROVIDER shall respond to CTC reports of System problems not resulting in
System Unavailability according to the following timeframes:
(1) Within seven (7) Calendar Days of receipt, the PROVIDER shall respond
in writing to notices of System problems.
(2) Within twenty (20) Calendar Days, the PROVIDER shall make a correction
to the System or will make a Requirements Analysis .and Specifications
document.
(3) The PROVIDER will correct the deficiency by a date certain as determined
by the CTC.
3. Testing
a. The PROVIDER shall work with the CTC pertaining to any testing initiative as
required by the CTC.
b. The PROVIDER shall ensure adequate Information System integrity to capture
Encounter Data and, at a minimum, take necessary action to safeguard against
System interruptions resulting from network, operating hardware, software, or
operational errors that compromise the integrity of transactions that are active in
.a live system or archived at the time of an outage or causing unscheduled
System Unavailability.
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F. Reporting Requirements - Specific to Information Management and Systems Functions and
Capabilities - and Technological Capabilities
1. Reporting Requirements
a. If the PROVIDER is extending access to "critical systems functions" to providers
and Medicaid Beneficiaries as described in the Availability of Critical Systems
Functions section, above, it shall submit a monthly Systems Availability and
Performance Report to the CTC as described in Reporting Requirements,
otherwise this reporting requirement is not applicable.
x. REPORTING REOUIREMENTS
A. General Reporting Requirements
1. The PROVIDER shall comply with all Reporting Requirements set forth by the CTC in this
Contract.
a. The PROVIDER is responsible for assuring the accuracy, completeness, and
timely submission of each report.
b. The PROVIDER shall certify the reports, attesting, based on his/her best
knowledge, information, and belief, that all data submitted in conjunction with
the reports or all documents requested by the CTC are accurate, truthful, and
complete.
c. The Certification shall be submitted at the same time the data reports are
submitted. The Certification page shall include a Certification that the data
submitted has been validated and the quality verified in accordance with this
Contract.
(1) Deadlines for report submission referred to in this Contract specify the
actual time of receipt at the CTC, not the date the PROVIDER postmarks
or transmits the file. The CTC shall date stamp a hard copy report or
send an email reply to an emailed report.
(2) The PROVIDER shall use the timeframes set forth in the table below for
submitting all reports.
d. Before November 1 of each year, the PROVIDER shall deliver to the CTC a
Certification that the PROVIDER has fairly and accurately presented all
Performance Measure data for the previous Agreement Year.
e. If a reporting due date falls on a weekend or State Holiday, the Agency must
receive the report on the following Business Day.
f. The PROVIDER shall file all quarterly reports based on a calendar year quarter.
Calendar year quarters are defined as the months ending March 31st, June 30th,
September 30th, and December 31st.
1 The CTC shall furnish the PROVIDER with the appropriate reporting formats, templates,
instructions, submission timetables, and technical assistance, as required.
2 The CTC reserves the right to modify the reporting requirements, with a sixty (60)
Calendar Day notice to allow the PROVIDER to complete implementation, unless
otherwise required by law.
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3 The erc shall provide the PROVIDER with written notification of any modifications to the
reporting requirements.
4. Unless otherwise specified, the PROVIDER shall record and submit all filings
electronically or mail a hard copy to the following address:
The Guidance/Care Center Inc., 3000 41st Street, Ocean * Marathon, FL 33050
5. Unless otherwise set forth below, or in a request for an ad hoc report, the PROVIDER
shall limit the scope of all reports to operations affecting Medicaid Beneficiaries and shall
not include in any report any outside, non-Medicaid or non~Medicaid Beneficiary related
information. The PROVIDER shall limit all reports and Performance Measures to
Transportation Services provided under this Agreement to Medicaid Beneficiaries and
shall not include other, non-Medicaid, services or operations that the PROVIDER
provides.
6. The PROVIDER shall grant the erc, or its representatives, full access to all financial and
statistical reports, supporting documents, and any other documents pertinent to this
Contract and the Transportation Provider Agreement. The PROVIDER shall provide the
documentation requested by the erc, or its representatives, in a manner that the erc
will provide when notifying the PROVIDER of the on-site surveys and desk reviews
7. The PROVIDER shall notify the erc's Project Manager within twenty-four (24) hours of
discovering a Violation of the protections provided by HIPAA.
Grievance Covers Hardcopy or Quarterly - Due 20 Calendar
System - Complaints, electronic format. Days after the end of the reporting
Summary Report Grievances, and Template quarter. Contains data for entire
Appeals related provided by the reporting quarter.
to Medicaid's erc.
NET Services.
Audited Financial Audited Hardcopyelectroni Annually -within 180 Calendar
Statement Statement. c format. Days after end of the Fiscal Year.
Financial and Reporting is for each calendar year.
Trip Travel Trip Travelby Hardcopy or Monthly -Due 5 Calendar Days
Expense Report Tri p. electronic format. after the month in which the
Expenses Template PROVIDER provided the Trip.
provided by the
erc.
Safety Copy of the Self- Hardcopy or Annually -Due January 10 of each
Compliance Self- Certification electronic format. year. Reporting is for each
Certification Report (Vehicle calendar year.
Report Inspections,
Driver Safety,
Drug and Alcohol
and Quality
monitorin
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Systems Outage Notification of a Email and/or 1m med iately occu rrence.
Notification Phone or System Phone call, upon
outage affecting followed by a
NET Services. summary report.
Template
provided by the
erc.
Hard copy,
format, or
Suspected Fraud Suspected electronic
Reporting Report. telephone Immediately upon occurrence.
Fraud
Critical Incidents Critical Incident Hardcopy or Upon Occurrence - Initial report
Report Report. electronic format. due one (1) Business Day after
Template learning of the incident. A written
provided by the final report shall be submitted to
ere. DCF the erc within 15 business days
template available after the incident. Detailed report
from DCF. to include measures to prevent
similar occurrences in the future.
Performance Performance Hardcopy or Monthly - Due 5 Calendar Days
Measures Measure electronic format. after the end of the reporting
information - month.
See Performance
Measure Section
for details.
B. Reporting Requirement Documents
1. Grievance System
a. The Grievance System report shall, include information based on the PROVIDER's
helpline and contain information about the number of Complaints, Grievances,
and Appeals received by the PROVIDER, its Subcontractors, and its local
Coordinating Board (lCB) concerning issues related to the provision of Non-
Emergency Transportation Services to Medicaid Beneficiaries only.
b. Refer to Attachment 4 for a template
2. Annual Financial Audit
a. The PROVIDER shall conduct an annual financial audit in accordance with federal
and State law, including, but not limited to, OMB Circular A-133 and Section
215.97, F.S., Florida Single Source Audit Act. The goal of the audit is to capture
the PROVIDER's financial information in a format for use by the erc, its Agents,
and federal and State auditors. The PROVIDER shall submit the audit annually,
along with a copy of the PROVIDER's Certification by hardcopy or in electronic
format to the ere. The PROVIDER shall limit the scope of the audit report it
submits to the erc to Transportation Services provided to Medicaid Beneficiaries.
If, at any time, the Recipient is determined to be a Vendor for purposes of OMB
Circular A-133 and/or the Florida Single Source Act, the Recipient shall still be
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required to submit an annual financial audit in accordance with the provisions of
OMS Circular A-133 and/or the Florida Single Source Act.
b. The erc does not provide a template for this report. Refer to Attachment 2 for
details on Special Audit Requirements.
3. Trip Travel Expense Report
a. The purpose of this report is to track the travel expenses incurred by the
PROVIDER for each Trip that incurs travel expenses, as set forth in the Covered
Services Section of this Contract.
b. Refer to Attachment 5 for a template.
4. Safety Compliance Self Certification Report
a. Self Certification - Each PROVIDER shaH submit an annual safety and security
Certification, in accordance with 14-90.10, F.A.C., to the erc, and shall submit to
any and all Safety and Security Inspections and Reviews in accordance with 14-
90.12, F.A.C. Each PROVIDER shall submit the total number of vehicle
inspections completed during the previous calendar year (January 1 through
December 31) and the results of said inspections by January 10th of each year.
b. The Safety Compliance Self Certification Report shall include, at a minimum, a
certification that the PROVIDER has instituted and are complying with the
following safety and monitoring procedures:
(1) Vehicle safety inspection;
(2) Drug and alcohol training and monitoring;
(3) Quarterly monitoring; and,
(4) Operator/driver training and monitoring.
c. The ere does not provide a template for this report.
5. Systems Outage Notification Report
a. The PROVIDER shall notify the ere Project Manager by electronic submission or
by telephone of a System outage immediately upon determination of a System
outage.
b. ' The PROVIDER shall submit the Business Disruption. Notification using the
template provided as a guideline. The Business Disruption Notification shall
provide the date and time the incident occurred, what eyent triggered the
outage, the plan of action to bring the System back online, the expected date
and time of recovery of the full use of the System, and the impact the System
outage has on Medicaid Beneficiaries.
c. The PROVIDER must submit a Systems Outage Report, in electronic format and
hardcopy, to the erc's Project Manager only if the PROVIDER's Information
Systems experience unscheduled downtime.
d. Refer to Report #6 for template.
6. Suspected Fraud Reporting
a. Upon detection of a potential or suspected Fraudulent encounter or act by a
Medicaid Beneficiary, the PROVIDER shall file a report with the ere. The ere will
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forward the report to the AHCA's Bureau of Medicaid Program Integrity.
b. The report shall contain at a minimum:
(1) The name of the Medicaid Beneficiary;
(2) The Medicaid Beneficiary's Medicaid identification number; and
(3) A description of the suspected Fraudulent act.
c. The erc does not provide a template for this report.
7. Critical Incident Reporting
a. The PROVIDER shall notify the erc within one (1) Business Day that there was a
critical incident.
b. The critical incident reporting requirements set forth in this Section do not
replace the abuse, Neglect, and exploitation reporting system established by the
State.
c. The definitions of reportable critical incidents are as follows:
(1) Death of a Medicaid Beneficiary that occurs while the Medicaid
Beneficiary is in a vehicle operated or contracted by the PROVIDER, due
to one (1) of the following:
(i) Suicide;
(ii) Homicide;
(iii) Abuse;
(iv) Neglect; or,
(v) An accident or other incident.
(2) Medicaid Beneficiary Injury or Illness - A medical condition that requires
medical treatment by a Health Care Professional and which is sustained,
or allegedly is sustained, due to an accident, act of Abuse, Neglect or
other incident occurring while a Medicaid Beneficiary is in a vehicle
operated or contracted by the PROVIDER.
(3) Sexual Battery - An allegation of sexual battery, as determined by
medical evidence or law enforcement involvement, by:
(i) A Medicaid Beneficiary on another Medicaid Beneficiary;
(ii) An employee of the PROVIDER, a Subcontractor, or a
Transportation Provider on a Medicaid Beneficiary; and/or,
(iii) A Medicaid Beneficiary on an employee of the. PROVIDER, a
Subcontractor, or a Transportation Provider.
(4) In addition to supplying the Critical Incidents Report, the PROVIDER shall
also report critical incidents in the manner prescribed by, and using the
template provided by, the appropriate district's DCF Alcohol, Drug Abuse
Mental Health office, using the appropriate DCF reporting forms and
procedures.
(5) Refer to Report #7 for a template.
8. Minority Participation Report
a. The ere encourages the PROVIDER to use Minority and Certified Minority
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businesses as subcontractors when procuring commodities or services to meet
the requirement of the Agreement.
The CTC requires information regarding the PROVIDER's use of minority owned
businesses as subcontractors for transportation services under this Agreement.
This information will be used for .assessment and evaluation of the CTC's Minority
Business Utilization Plan. During the term of the Agreement, it will be necessary
for the PROVIDER to maintain this information monthly. A minority owned
business is defined as any business enterprise owned and operated by the
following ethnic groups: African American (Certified Minority Code H or Non-
Certified Minority Code N), Hispanic American (Certified Minority Code I or Non.-
Certified Minority 0), Asian American (Certified Minority Code J or Non-Certified
Minority Code P), Native American (Certified Minority Code K or Non-Certified
Minority Code Q), or American Woman (Certified Minority Code M or Non-
Certified Minority Code R). The PROVIDER should retain this information and
make it available upon request by the erc.
XI METHOD OF PAYMENT
A. Fixed Price Fixed Fee Agreement
1 The CTC shall pay the PROVIDER, upon satisfactory completion of all terms and
conditions specified in the Agreement, a total amount included in Exhibit B.
2 The PROVIDER shall request payment through submission of a properly completed
invoice to the CTC. Invoices shall be submitted in a format provided by the CTC.
3 The CTC's performance and obligation to pay under this Agreement is contingent upon
an annual appropriation by the Legislature.
4 Errors
a. If, after preparation and submission of reports and/or invoices, the PROVIDE~
discovers an error, including, but not limited to, errors resulting in incorrect
payments, either by the PROVIDER or the CTC, the PROVIDER has thirty (30)
Business Days from its discovery of the error, or thirty (30) Business Days after
receipt of notice by the CTC to correct the error and resubmit accurate reports
and/or invoices. Failure to respond within the thirty (30) Business Day period
shall result in a loss of any money due to the PROVIDER for such errors and/or
sanctions against the PROVIDER pursuant to Sanctions Section of this Contract.
B. Member Payment Liability Protection
1. Pursuant to Section 1932 (b)(6), Social Security Act (as enacted by Section 4704 of the
Balanced Budget Act of 1997), the PROVIDER shall not hold Medicaid Beneficiaries liable
for the following:
a~ For debts of the PROVIDER, in the event of the PROVIDERs Insolvency;
b~ For payment of Covered Services provided by the PROVIDER if the PROVIDER
has not received payment from the CTC for the Covered Services, and/or,
c. For payments to a PROVIDER that furnished Covered Services under a contract,
or other arrangement with the PROVIDER, that are in excess of the amount that
normally would be paid by the Medicaid Beneficiary if the Covered Services had
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been received directly from the PROVIDER.
XII. SANCTIONS
A. General Provisions
1. The PROVIDER shall comply with all requirements and performance standards set forth
in this Contract. In the event the CTC identifies a Violation of this Contract, or other
non-compliance with this Contract, the PROVIDER shall submit a Corrective Action Plan
(CAP) within three (3) Calendar Days of the date of receiving notification of the Violation
or non-compliance from the CTC or within the timeframe specified by the CTC,
whichever is later.
a. Within five (5) Business Days of receiving the CAP the CTC will either approve or
disapprove the CAP. If disapproved, the CTC must cite the specific reasons in a
written format for said disapproval. Upon written notice of disapproval, the.
PROVIDER shall resubmit, within five (5) Business Days, or a date specified by
the CTC whichever is later, a new CAP that addresses the concerns identified by
the CTC.
b. Upon approval of the CAP, whether the initial CAP or the revised CAP, the
PROVIDER shall implement the CAP within the time frames specified by the erc.
The PROVIDER shall submit a report to the CTC detailing the implementation of
the PROVIDER's CAP forty-five (45) Business Days following the date of the
CTC's approval of the CAP.
c. Except where specified below, the CTC shall impose a monetary sanction of $100
per day on the PROVIDER for each Calendar Day that the PROVIDER does not
implement the approved CAP to the satisfaction of the CTC.
2. If the CTC determines, in its sole discretion, that a PROVIDER and/or Transportation
Provider has violated the terms of this Contract, the CTC can sanction the PROVIDER,
can terminate this Contract, or both. If the Agency for Health Care Administration
determined, in its sole discretion, that a PROVIDER and/or Transportation Provider has
violated the terms of this contract, AHCA can sanction the CTC and request the this
contract be terminated or both.
3. Unless the CTC specifies the duration of a sanction, the sanction shall remain in effect
until the CTC is satisfied that the PROVIDER has corrected the basis for imposing the
sanction and it is not likely to recur.
B. Specific Sanctions
1. The CTC may impose any of the following sanctions against the PROVIDER if the CTC, in
its sole discretion, determines that the PROVIDER and/or a Transportation Provider has
violated any provision of this Agreement, or any applicable statutes:
a. Suspension or revocation of payments to the PROVIDER for Medicaid
Beneficiaries during the sanction period;
b. For any nonwillful Violation of the Agreement, the CTD shall impose a fine, not to
exceed $2,500 per Violation. In no event shall such fine exceed an aggregate
amount of $10,000 for all nonwillful Violations arising out of the same action; .
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c. With respect to any knowing and willful Violation of the Agreement, the CTD
shall impose a fine upon the PROVIDER in an amount not to exceed $20,000 for
such Violation. In no event shall such fine exceed an aggregate amount of
$100,000 for all knowing and willful Violations arising out of the same action;
d. If the PROVIDER fails to carry out substantive terms of the Agreement, the ere
shall terminate the Agreement. After the CTC notifies the PROVIDER that it
intends to terminate the Agreement, the CTC shall give the PROVIDER's Medicaid
Beneficiaries written notice of the CTC's intent to terminate the Agreement.
e. The CTD may impose intermediate sanctions, including, but not limited to civil
monetary penalties in the amounts specified in this Agreement.
f. Suspension of payment for Medicaid Beneficiaries after the effective date of the
sanction and until the CTD is satisfied that the reason for imposition of the
sanction no longer exists and is not likely to recur; and/or
g. Before imposing any intermediate sanctions, the CTD must give the PROVIDER
timely notice.
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EXHIBIT B
METHOD OF COMPENSATION
This Exhibit defines the limits of compensation to be made to the contractor for the services set forth in
Exhibit "A" and the method by which payments shall be made.
1. Project Compensation:
For the satisfactory performance of services detailed in Exhibit "A", the PROVIDER shall be paid
up to a Maximum Amount of $ 70,000 during the length of the contract.
The Provider shall not provide services that exceed the limiting amount(s) without an approved
Amendment from the ere. The total amount of this contract is contingent upon annual appropriation
by the Legislature.
Currently, $70,000 of the total amount has been approved and encumbered for this contract.
Therefore, it is agreed that the PROVIDER will not be obligated to perform services nor incur costs
which would result in exceeding the funding currently approved; nor will the erc be obligated to
reimburse the PROVIDER for costs or make payments in excess of currently established funding. The
erc will provide written authorization if and when subsequent funding is approved and encumbered for
this contract.
The Provider shall request payment through submission of a properly completed invoice to the CTC's
Transportation Director or its designee.
Monroe County Transportation:
$3.00 per milej5 mile minimum
$2.00 per mile for preauthorized out-af-county trips
$3.00 flat rate per client per mu'ltiload
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ATTACHMENT 1
BUSINESS ASSOCIATE AGREEMENT
The parties to this Attachment agree that the following provisions constitute a business associate
agreement for purposes of complying with the requirements of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). This Attachment is applicable if the Recipient is a business
associate within the meaning of the Privacy and Security Regulations, 45 C.F.R. 160 and 164.
The Recipient certifies and agrees as to abide by the following:
1. Definitions. Unless specifically stated in this Attachment, the definition of the terms contained
herein shall have the same meaning and effect as defined in 45 C.F.R. 160 and 164.
1.a. Protected Health Information. For purposes of this Attachment, protected health
information shall have the same meaning and effect as defined in 45 C.F.R. 160 and
164, limited to the information created, received, maintained or transmitted by the
Recipient from, or on behalf of, the Agency.
1.b. Security Incident. For purposes of this Attachment, security incident shall mean any
event resulting in computer systems, networks, or data being viewed, manipulated,
damaged, destroyed or made inaccessible by an unauthorized activity. See National
Institute of Standards and Technology (NIST) Special Publication 800-61, "Computer
Security Incident Handling Guide," for more information.
2. Use and Disclosure of Protected Health Information. The Recipient shall not use or disclose
protected health. information other than as permitted by this Agreement or by federal and state
law. The Recipient will use appropriate safeguards to prevent the use or disclosure of protected
health information for any purpose not in conformity with this Agreement and federal and state
law. The Recipient will implement administrative, physical, and technical safeguards that
reasonably and appropriately protect the confidentiality, integrity, and availability of electronic
protected health information the Recipient creates, receives, maintains, or transmits on behalf
of the Agency.
3. Use and Disclosure of Information for Management. Administration. and Legal Responsibilities.
The Recipient is permitted to use and disclose protected health information received from the
Agency for the proper management and administration of the Recipient or to carry out the legal
responsibilities of the Recipient, in accordance with 45 C.F.R. 164.S04(e)(4). Such disclosure is
only permissible where required by law, or where the Recipient obtains reasonable assurances
.from the person to whom the protected health information is disclosed that: (1) the protected
health information will be held confidentially, (2) the protected health information will be used
or further disclosed only as required by law or for the purposes for which it was disclosed to the
person, and (3) the person notifies the Recipient of any instance of .which it is aware in which
the confidentiality of the protected health information has been breached.
4. Disclosure to Third Parties. The Recipient will not divulge, disclose, or communicate protected
health information to any third party for any purpose not in conformity with this Agreement
without prior written approval from the Agency. The Recipient shall ensure that any agent,
including a subcontractor, to whom it provides protected health information received from, or
created or received by the Recipient on behalf of, the Agency agrees to the same terms,
conditions, and restrictions that apply to the Recipient with respect to protected health
information.
5. Access to Information. The Recipient shall make protected health information available in
accordance with federa.l and state law, including providing a right of access to persons who are
the subjects of the protected health information in accordance with 45 C.F.R. 164.524.
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6. Amendment and Incorporation of Amendments. The Recipient shall make protected health
information available for amendment and to incorporate any amendments to the protected
health information in accordance with 45 C.F.R. ~ 164.526.
7. Accounting for Disclosures. The Recipient shall make protected health information available as
required to provide an accounting of disclosures in accordance with 45 C.F.R. ~ 164.528. The
Recipient shall document all disclosures of protected health information as needed for the
Agency to respond to a request for an accounting of disclosures in accordance with 45 C.F.R. ~
164.528.
8. Access to Books and Records. The Recipient shall make its internal practices, books, and
records relating to the use and disclosure of protected health information received from, or
created or received by the Recipient on behalf of the Agency, available to the Secretary of the
Department of Health and Human Services or the Secretary's designee for purposes of
determining compliance with the Department of Health and Human Services Privacy
Regulations.
9. Reporting. The Recipient shall make a good faith effort to identify any use or disclosure of
protected health information not provided for in this Agreement. The Recipient will report to the
Agency, within ten (10) business days of discovery, any use or disclosure of protected health
information not provided for in this Agreement of which the Recipient is aware. The Recipient
will report to the Agency, within twenty-four (24) hours of discovery, any security incident of
which the Recipient is aware. A violation of this paragraph shall be a material violation of this
Agreement.
10. Termination. Upon the Agency's discovery of a material breach of this Attachment, the Agency
shall have the right to terminate this Agreement.
lO.a. Effect of Termination. At the termination of this Agreement, the Recipient shall return all
protected health information that the Recipient still maintains in any form, including any
copies or hybrid or merged databases made by the Recipient; or with prior written
approval of the Agency, the protected health information may be destroyed by the
Recipient after its use. If the protected health information is destroyed pursuant to the
Agency's prior written approval, the Recipient must provide a written confirmation of
such destruction to the Agency. If return or destruction of the protected health
information is determined not feasible by the Agency, the Recipient agrees to protect
the protected health information and treat it as strictly confidential.
The Recipient has caused this Attachment to be signed and delivered by its duly authorized
representative, as of the date set forth below.
Agency Name: Honr~
Signature . ...~
Date
1/'0/10
Name.8t\d:.l1tieofA\lthprized Signer Syl. via J. Murphy ~ Mayor I Chainaan
COUN-rV AT'"
V,- AS T F
\~~/~L~ PED 0 J. r E CA 0
.":~/:;;,, ..:;,~;;t: ~ . AC~IC'TANT CO ". c
.:.~:.;ir0~~~~ '''. .... n . ~\V \oJ. ~
, . .;,'.' t~.t,;:;:~ EPIJT'(. ~ Oc)8.IB '':_".~~_..'~r_rr.O<'_'A'~_''''-''~-''~-_.'~~'
<.:'--..-c .,,-- .,
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ATTACHMENT 2
SPECIAL AUDIT REQUIREMENTS
The administration of resources awarded by the Commission for the Transportation Disadvantaged
(which may be referred to as the "Agency" or "Grantor") to the recipient (which may be referred to as
the "Vendor", "Facility" or "Recipient") may be subject to audits and/or monitoring by the CTC, as
described in this Attachment.
MONITORING
In addition to reviews of audits conducted in accordance with OMS Circular A-133 and Section 215.97,
F.S., as revised (see "AUDITS" below), monitoring procedures may include, but not be limited to, on-
site visits by CTC staff, limited scope audits as defined by OMS Circular A-133, as revised, and/or other
procedures. Sy entering into this Agreement, the Recipient agrees to comply and cooperate with any
monitoring procedures/processes deemed appropriate by the CTC. In the event the CTC determines
that a limited scope audit of the Recipient is appropriate, the Recipient agrees to comply with any
additional instructions provided by the CTC staff to the Recipient regarding such audit. The Recipient
further agrees to comply and cooperate with any inspections, reviews, investigations, or audits deemed
necessary by the Chief Financial Officer (CFO) or Auditor General.
AUDITS
PART I: FEDERALLY FUNDED
Recipients of federal funds (i.e. state, local government, or non-profit organizations as defined in OMS
Circular A-1233, as revised) are to have audits done annually using the following criteria:
1 In the event that the recipient expends $500,000 or more in Federal awards in its fiscal year,
the Recipient must have a single or program-specific audit conducted in accordance with the
provisions of OMS Circular A-133, as revised. EXHIBIT 1 to this agreement indicates Federal
resources awarded through the Agency for Health Care Administration 'by this Agreement. In
determining the Federal awards exp'ended in its fiscal year, the Recipient shall consider all
sources of Federal awards, including Federal resources received from the CTD. The
determination of amounts of Federal awards expended should be in accordance with the
guidelines established by OMS Circular A-133, as revised. An audit of the Recipient conducted
by the Auditor General in accordance with the provisions OMS Circular A-133, as revised, will
meet the requirements of this part.
2 In connection with the audit requirements addressed in Part I, paragraph 1, the Recipient shall
fulfill the requirements relative to auditee responsibilities as provided in Subpart C of OMB
Circular A-133, as revised.
3 If the Recipient expends less than $500,000 in Federal awards in its fiscal year, an audit
conducted in accordance with the provisions of OMS Circular A-133, as revised, is not required.
However, if the recipient elects to have an audit conducted in accordance with the provisions of
OMS Circular A-133, as revised, the cost of the audit must be paid from non-Federal resources
(i.e., the cost of such an audit must be paid from Recipient resources obtained from other than
Federal entities).
4 Federal awards are to be identified using the Catalog of Federal Domestic Assistance (CFDA)
title and number, award number and year, and name of the awarding federal agency. The
Recipient may access information regarding the Catalog of Federal Domestic Assistance (CFDA)
via the internet at http://12.46.245.173/dda/cfda.html.
PART II: STATE FUNDED
Recipients of state funds (i.e. a nonstate entity as defined by Section 215.97(2)(1), Florida Statutes) are
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to have audits done annually using the following criteria
1 In the event that the Recipient expends a total amount of state financial assistance equal to or
in excess of $500,000 in any fiscal year of such Recipient, the Recipient must have a State
single or project-specific audit for such fiscal year in accordance with Section 215.97, Florida
Statutes; applicable rules of the Department of Financial Services; and Chapters 10.550 (local
govern me.nta I entities) or 10.650 (nonprofit and for-profit organiz.ations), Rules of the Auditor
General. EXHIBIT 1 to this agreement indicates state financial assistance awarded through the
erc by this Agreement. In determining the state financial assistance expended in its fiscal year,
the Recipient shall consider all sources of state financial assistance, including state financial
assistance received from the erc, other state agencies, and other nonstate entities. State
financial assistance does not include Federal direct or pass-through awards and resources
received by a nonstate entity for Federal program matching requirements.
2 In connection with the audit requirements addressed in Part II, paragraph 1, the Recipient shall
ensure that the audit complies with the requirements of Section 215.97(8), Florida Statutes.
This includes submission of a financial reporting package as defined by Section 215.97(2),
Florida Statutes, and Chapters 10.550 (local governmental entities) or 10.650 (nonprofit and
for-profit organizations), Rules of the Auditor General.
3 If the Recipient expends less than $500,000 in state financial assistance in its fiscal year, an
audit conducted in accordance with the provisions of Section 215.97, Florida Statutes, is not
required. However, if the recipient elects to have an audit conducted in accordance with the
provisions of Section 215.97, Florida Statutes, the cost of the audit must be paid from the
nonstate entity's resources (i.e., the cost of such an audit must be paid from the recipient's
resources obtained from other than State
4 State awards are to be identified using the Catalog of State Financial Assistance (CSFA) title and
number, award number and year, and name of the state agency awarding it. For information
regarding the Florida Catalog of State Financial Assistance (CSFA), a Recipient should access
the Florida Single Audit Act website located at https://apps.fldfs.com/fsaa/.
PART III: OTHER AUDIT REQUIREMENTS
The recipient shall follow up and take corrective action on audit findings. Preparation of a summary
schedule of prior year audit findings, including corrective action and current status of the audit findings
is required. Current year audit findings require corrective action and status of findings.
Records related to unresolved audit findings, appeals, or litigation shall be retained until the action is
completed or the dispute is resolved. Access to project records and audit work papers shall be given to
the erD, the Department of Financial Services, and the Auditor General. This section does not limit the
authority of the erc to conduct or arrange for the conduct of additional audits or evaluations of state
financial assistance or limit the authority of any other state official.
(NOTE: This part would be used to specify any additional audit requirements imposed by the State
awarding entity that are solely a matter of that State awarding entity's policy (i.e., the audit is not
required by Federal or State laws and is not in conflict with other Federal or State audit requirements).
Pursuant to Section 215.97(8), Florida Statutes, State agencies may conduct or arrange for audits of
state financial assistance that are in addition to audits conducted in accordance with Section 215.97,
Florida Statutes. In such an event, the State awarding agency must arrange for funding the full cost of
such additional audits.)
PART IV: REPORT SUBMISSION
1. Copies of reporting packages for audits conducted in accordance with OMB Circular A-133, as
revised, and required by PART lof this agreement shall be submitted, when required by Section
.320 (d), OMB Circular A-133, as revised, by or on behalf of the recipient directly to each of the
following:
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A. The Department at the following address:
Executive Director
Commission for the Transportation Disadvantaged 605 Suwannee Street, MS-
49Tallahassee, Florida 32399-0450
B The Federal Audit Clearinghouse designated in OMB Circular A-133, as revised (the
number of copies required by Sections .320 (d)(l) and (2), OMB Circular A-133, as
revised, should be submitted to the Federal Audit Clearinghouse), at the following
address:
Federal Audit Clearinghouse Bureau of the Census 1201 East 10th Street Jeffersonville,
IN 47132
C. Other Federal agencies and pass-through entities in accordance with Sections .320 (e)
and (f), OMB Circular A-133, as revised.
2. In the event that a copy of the reporting package for an audit required by PART I of this
agreement and conducted in accordance with OMB Circular A-133, as revised, is not required to
be submitted to the erc for the reasons pursuant to Section .320 (e)(2), OMB Circular A-133,
as revised, the recipient shall submit the required written notification pursuant to Section .320
(e)(2) and a copy of the recipient's audited schedule of expenditures of Federal awards directly
to each of the following
Executive Director
Commission for the Transportation Disadvantaged 605 Suwannee Street, MS-
49Tallahassee, Florida 32399-0450
In addition, pursuant to Section .320 (f),OMB Circular A-133, as revised, the recipient shall
submit a copy of the reporting package described in Section .320 (c), OMB Circular A-133, as
revised, and any management letters issued by the auditor, to the erc at each of the following
addresses:
Executive Director
Commission for the Transportation Disadvantaged 605 Suwannee Street, MS-
49Tallahassee, Florida 32399-0450
3. Copies of financial reporting packages required by PART II of this agreement shall be submitted
by or on behalf of the recipient directly to each of the following:
A. The erc at the following address:
Executive Director
Guidance/Care Center, Inc. * 3000 41st Street, Ocean * Marathon, FL 33050
B. The Auditor General's Office at the following address:
Auditor General's Office Room 401, Pepper Building 111 West Madison Street
Tallahassee, Florida 32399-1450
4. Copies of reports or the management letter required by PART III of this agreement shall be
submitted by or on behalf of the recipient directly to:
A. The erc at the following address:
Executive Director
Commission for the Transportation Disadvantaged 605 Suwannee Street, MS-
49Tallahassee, Florida 32399-0450
Any reports, management letter, or other information required. to be submitted to the
Department pursuant to this Agreement shall be submitted timely in accordance with OMS
Circular A-133, Florida Statutes, and Chapters 10.550 (local governmental entities) or 10.650
(nonprofit and for-profit organizations), Rules of the Auditor General, as applicable.
5. Recipients, when submitting financial reporting packages to the erc for audits done in
accordance with OMS Circular A-133 or Chapters 10.550 (local governmental entities) or 10.650
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(nonprofit and for-profit organizations), Rules of the Auditor General, should indicate the date
that the reporting package was delivered to the Recipient in correspondence accompanying the
reporting package.
PART V: RECORD RETENTION
The Recipientshall retain sufficient records demonstrating its compliance with the terms of this
Agreement for a period of five (5) years from the date the audit report is issued, and shall allow the
CTC, or its designee, CFa, or Auditor General access to such records upon request. The Recipient shall
ensure that audit working papers are made available to the CTC, or its designee, CFO, or Auditor
General upon request for a period of three (3) years from the date the audit report is issued, unless
extended in writing by the CTC.
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C 0
ATTACHMENT 3
QUARTERLY GRIEVANCE SYSTEM SUMMARY REPORT
PROVIDER
Dates of Quarter Reporting:
Complaints Grievances Appeals
County Total Total Resolved Not Resolved I Not I Total Resolved Not Resolved I Not I Total
Open by LCB , Resolved by STP Resolved i by LCB I Resolved by STP Resolved j
> 15 by LCB by STP ' by LCB ! by STP
' Days I
I
i
Total � [ I
Y
Report is due 20 Calendar Days after the end of the reporting quarter. PROVIDER must report all data
until closed.
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-72-
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ATTACHMENT 5
BUSINESS DISRUPTION NOTIFICATION REPORT
PROVIDER Name:
Reporting Period: County:
System(s) Affected Description of Outage Population Affected
Computer System
Telephony System
The date and time the
incident occurred
What event triggered the
incident
The plan of action to bring
the System back online
The expected date and
time of recovery of full
use of the System
The impact the outage
had on Medicaid
Beneficiaries
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ATTACHMENT 6
CRITICAL INCIDENT REPORT
PROVIDER Name:
Reporting Period:
County of Incident:
Time of Incident:
Location of Incident:
Critical Incident Type:
Details of Incident (Include Medicaid
Benefic"iary's age, gender, diagnosis,
current medication, source of information,
all reported details about the event,
action taken by
CTC/Subcontractor /Transportation
Provider, and any other pertinent
information):
Follow Up Planned or Required
(Include information relating to any
CTC/Subcontractor /Transportation
Provider policy or procedure that applies
to the event):
Transportation Provider:
Report Submitted By:
Date of Submission:
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ATTACHMENT 7
DEFINITIONS AND ACRONYMS
A. Definitions
The following terms as used in this Agreement shall be construed and/or interpreted as follows, unless
the Agreement otherwise expressly requires a different construction and/or interpretation.
Abuse - Practices that are inconsistent with generally accepted business or Transportation practices
and that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or
services that are not Medically Necessary or that fail to meet professionally recognized standards for
health care; or Medicaid Beneficiary practices that result in unnecessary cost to the Medicaid program.
Action - (i) The denial or limited authorization of a requested service, including the type or level of
service, pursuant to 42 CFR 438.400(b). (ii) The reduction, suspension, or termination of a previously
authorized service. (iii) The denial, in whole or in part, of payment for a service. (iv) The failure to
provide services in a timely manner, as defined by the State. (v) The failure of the Recipient to resolve
a Complaint within fifteen (15) Business Days, a Grievance within ninety (90) Calendar Days, and an
Appeal within forty-five (45) Ca.lendar Days from the date the Recipient/Subcontractor receives the
Complaint, Grievance, or Appeal.
Acute Condition - An Acute Condition is a medical condition with a rapid onset of symptoms and/or a
temporary or limited duration (as opposed to a Chronic Condition) and includes subacute conditions.
Treatment for an Acute Condition 'is intended to last a short duration and may include surgical
treatment, rehabilitative treatment, and/or other care.
Agency - State of Florida, Agency for Health Care Administration.
Agent -An entity that contracts with the State to perform administrative functions, including but not
limited to: Fiscal Agent activities, outreach and education, eligibility activities; Systems and technical
support.
Agreement - The Agreement between the Recipient and the Agency to provide Medicaid Non-
Emergency Transportation Services to Medicaid Beneficiaries, comprised of the Agreement, and any
addenda, appendices, attachments, or amendments thereto.
Agreement Period - The term of the Agreement from December 1, 2008 through August 31, 2011.
Appeal- A request for review of an Action, pursuant to 42 CFR 438.400(b).
Attendant/Escort - An Attendant/Escort is an individual whose presence is required to assist a
Medicaid Beneficiary during transport and at the place of treatment.
Baker Act - The Florida Mental Health Act, pursuant to ss. 394.451-394.4789, F.S.
Behavioral Health Care - Services listed in the Community Behavioral Health Services Coverage &
Limitations Handbook and the Targeted Case Management Coverage & Limitations Handbook.
Behavioral Health Care involves issues relating to mental health and substance abuse.
Business Days - Traditional workdays, which are Monday, Tuesday, Wednesday, Thursday, and
Friday, excluding State Holidays.
Calendar Days - All seven (7) days of the week.
Certification - The process of determining that a facility, equipment or an individual meets the
requirements of federal or State law, or whether Medicaid payments are appropriate or shall be made
in certain situations.
Children/Adolescents - Medicaid Beneficiaries under the age of twenty-one (21).
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Chronic Condition - A Chronic Condition is a medical condition that is long lasting or recurrent.
Chronic Conditions require ongoing management for effective long term treatment.
Complaint - An expression of dissatisfaction about any matter other than an Action. Possible subjects
for Complaint include, but are not limited to, the quality of Transportation Services, the quality of
services provided and aspects of interpersonal relationships such as rudeness of a Transportation
Provider or employee or failure to respect the Medicaid Beneficiary's rights. A Complaint is resolved at
the Point of Contact rather than through filing a formal Grievance.
Contracting Officer - The Secretary of the Agency or his/her delegate.
Cost - Fully allocated expenses associated with providing Transportation Services to Medicaid
Beneficiaries. The Recipient may determine Cost by using the Recipient's approved rate calculation
model or a Recipient approved rate calculation model consistently utilized by a Subcontractor.
Cost Effective - Economical in terms of the goods or services received for the Covered Services -
Those services provided by the Recipient in accordance with this Agreement, and as outlined in Section
V, Covered Services, in this Agreement. Also referred to as "Transportation Services."
Cultural Competency Plan - A required written plan that the Recipient must maintain in accordance
with 42 CFR 438.206. The Cultural Competency Plan describes how the Recipient will ensure that it
provides Transportation Services in a culturally competent manner to all Medicaid Beneficiaries,
including those with limited English proficiency.
Disclosing Entities - The Recipient and any Subcontractors that furnish services or arrange for
furnishing services under this Agreement.
Emergency Transportation - The provision of Emergency Transportation Services in accordance
with Section 409.908(13)(c)(4), F.S.
Encounter Data - Encounter Data includes records of Covered Services provided by the Recipient to a
Medicaid Beneficiary.
Expedited Appeal Process - The process by which the Appeal of an Action is accelerated because
the standard time-frame for resolution of the Appeal could seriously jeopardize the Medicaid
Beneficiary's life, health, or ability to obtain, maintain, or regain maximum function.
External Quality Review (EQR) - The analysis and evaluation by an External Quality Review
Organization (EQRO) of aggregated information on Quality, timeliness, and access to the health care
services that are furnished to Medicaid Beneficiaries by the. Recipient.
External Quality Review Organization (EQRO) - An organization that meets the competence and
independence requirements set forth in federal regulations 42 CFR 438.354, and performs EQR, other
related activities as set forth in federal regulations, or both.
Family Planning Waiver (FPW) - The Family Planning Waiver extends eligibility for family planning
services for twenty-four (24) months to postpartum women capable of bearing a child who have lost
Medicaid eligibility.
Fee-tor-Service (FFS) - A method of making payment by which the Agency sets prices for defined
medical or allied care, goods, or services.
Fiscal Agent - Any corporation, or other legal entity, that enters.into a contract with the Agency to
receive, process, and adjudicate claims under the Medicaid program.
Fiscal Year - The State of Florida's Fiscal Year starts July 1 and ends on June 30. This may be
different than the Agreement Year.
Florida Medicaid Management Information System (FMMIS) - The information system used to
process Florida Medicaid claims and payments to Recipients, and to produce management information
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and reports relating to the Florida Medicaid program. The State uses this system to maintain Medicaid
eligibility data and provider enrollment data.
Fraud - An intentional deception or misrepresentation made by a person with the knowledge that the
deception results in unauthorized benefit to herself or himself or another person. The term includes any
act that constitutes fraud under applicable federal or state law.
Grievance - An expression of dissatisfaction about any matter other than an Action. Possible subjects
for Grievances include, but are' not limited to, the quality of Transportation Services provided and
aspects of interpersonal relationships such as rudeness of a Provider or employee or failure to respect
the Medicaid Beneficiary's rights.
Grievance Procedure - The procedure for addressing Medicaid Beneficiaries' Grievances.
Grievance System- The system for reviewing and resolving Medicaid Beneficiary Grievances and
Appeals. Components must include a Complaint Procedure, a Grievance Procedure, an Appeal process,
and access to the Medicaid Fair Hearing system.
Health Care Professional - A physician or any of the following, including, but not limited to:
podiatrist, optometrist, chiropractor, psychologist, dentist, physician assistant, physical or occupational
therapist, therapist assistant, speech-language pathologist, audiologist, Registered Nurse or practical
Nurse (including nurse practitioner, clinical nurse specialist, certified Registered Nurse anesthetist and
certified nurse midwife), a Licensed certified social worker, registered respiratory therapist and certified
respiratory therapy technician.
Hospital - A facility Licensed in accordance with the provisions of Chapter 395, Florida Statutes or
the applicable laws of the state in which the service is furnished.
Household - Includes all persons residing at a common address.
Information - (i) Structured Data: data that adhere to specific properties and Validation criteria that
are stored as fields in database records. Structured queries can be created and run against structured
data, where specific data can be used as criteria for querying a larger data set; (ii) Document:
information that does not meet the definition of structured data; includes text, files, spreadsheets,
electronic messages, images of forms, and pictures.
Information System(s) - A combination of computing hardware and software that is used in: (a)
the capture, storage, manipulation, movement, control, display, interchange, and/or transmission of
information (i.e. structured data, which may include digitized audio and video), and documents; and/or
(b) the processing of such information for the purposes of enabling and/or facilitating a business
process or related transaction.
Insolvency - A financial condition that exists when an entity is unable to pay its debts as they
become due in the usual course of business, or when the liabilities of the entity exceeds its assets.
Institutional Care Program (ICP) Residents - Medicaid Beneficiaries who are eligible for
placement in a facility while their eligibility determination is being processed (e.g., nursing home
residents, etc.).
Licensed - A facility, equipment, or individual that has formally met State, county, and local
requirements, and has been granted a license by a local, State, or federal government entity.
List of Excluded Individuals and Entities (LEIE) - A database maintained by the Department of
Health & Human Services, Office of the Inspector General. The LEIE provides information to the public,
health care providers, patients and others relating to parties excluded from participation in Medicare,
Medicaid, and all other federal health care programs. The LEIE includes the Department of
Management Services' List of Excluded Vendors.
Managed Care Organization (MeO) - An organization, either for-profit or not-for-profit, in which an
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organization, such as an HMO, PSN, or EPO, acts as an intermediary between the Medicaid Beneficiary
seeking care and the physician.
Medicaid - The medical assistance program authorized by Title XIX of the Social Security Act, 42
U.S.C. ~1396 et seq., and regulations there under, as administered in the State of Florida by the
Agency under 409.901 et seq., F.S.
Medicaid Beneficiary - Any individual whom Department of Children and Families (DCF) or the
Social Security Administration determines is eligible, pursuant to federal and State law, to receive
medical or allied care, goods, or services for which the Agency may make payments under the Medicaid
program, and who is enrolled in the.Medicaid program.
Medicaid Eligibility Vendor System (MEVS) - An entity that provides Medicaid eligibility status to
Medicaid providers. A MEVS 'vendor does not necessarily provide the Non-Emergency Transportation
eligibility status of a Medicaid Beneficiary.
Medicaid Reform - The program resulting from Chapter 409.91211, F.S.
Medically Needy - A Medicaid Beneficiary who would qualify for Medicaid but has income or
resources that exceed normal Medicaid guidelines. On a month-by-month basis, the State determines
the individ'ual's eligibility by subtracting the individual's medical expenses from his/her income; if the
remainder falls below Medicaid's income limits, the individual may qualify for Medicaid through the end
of the month.
Medica'lly Necessary or Medical Necessity - Services that include medical or allied care, goods, or
services furnished or ordered to:
1. Meet the following conditions:
a. Be necessary to protect life, to prevent significant illness or significant disability or to alleviate
severe pain;
b. Be individualized, specific and consistent with symptoms or confirm diagnosis of the illness or
injury under treatment and not in excess of the patient's needs;
c. Be consistent with the generally accepted professional medical standards as determined by
the Medicaid program, and not be experimental or investigational;
d. Be reflective of the level of service that can be furnished safely and for which no equally
effective and more conservative or less costly treatment is available statewide; and
e. Be furnished in a manner not primarily intended for the convenience of the Medicaid
Beneficiary, the Medicaid Beneficiary's caretaker or the provider.
2. Medically Necessary or Medical Necessity for those services furnished in a Hospital on an
inpatient basis cannot, consistent with the provisions of appropriate medical care, be effectively
furnished more economically in a Nursing Facility basis or in an inpatient facility of a different
type.
3. The fact that a Licensed Health Care Professional has prescribed, recommended, or approved
medical or allied goods or services does not, in itself, make such care, goods, or services
Medically Necessary, a Medical Necessity, or a Covered Service.
Medicare - The medical assistance program authorized by Title XVIII of the Social Security Act.
Mile/Mileage - Distance that Transportation Providers log for each Medicaid Beneficiary. Mile/Mileage
starts at the location that the Transportation Provider picks up the Medicaid Beneficiary and ends at the
location at which the Transportation Provider delivers the Medicaid Beneficiary.
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Neglect - A failure or omission to provide care, supervi~ion, and/or services necessary to maintain a
Medicaid Beneficiary's physical and mental health, including but not limited to, food, nutrition,
supervision, medical services, and Transportation Services that are essential for the well-being of the
Medicaid Beneficiary. Neglect might be a single incident or repeated conduct that results in, or could
reasonably be expected to result in, serious physical or psychological injury, .or a substantial risk of
death.
No Show - If a Medicaid Beneficiary fails to provide a cancellation notice to the Recipient or a
Transportation Provider at least twenty-four (24) hours in advance of a scheduled Trip, or the Medicaid
Beneficiary is not available or has decided he/she does not require Transportation Services, then the
Recipient shall classify the Medicaid Beneficiary as a .No Show.
Non-Covered Service - A service that does not qualify as one of the Recipient's Covered Services.
Non-Emergency Transportation Services Coverage 8l Limitations Handbook (Handbook) -
A document that provides information to a Transportation Provider regarding Medicaid Beneficiary
eligibility, claims submission and processing, Transportation Provider participation, covered care, goods
and services, limitations, procedure codes and fees, and other matters related to participation in the
Medicaid program.
Nursing Facility - An institutional care facility that furnishes medical or allied inpatient care and
services to individuals needing such services. See Chapters 395 and 400, F.S.
Outpatient ~ A patient of an organized medical facility, or distinct part of that facility (such as a
Hospital), whom a facility expects to receive, and who does receive, professional services for less than
a twenty-four (24) hour period, regardless of the hours of admission, whether or not a bed is used
and/or whether or not the patient remains in the facility past midnight.
Overpayment - Includes any amount that is not authorized to be paid by the Medicaid program
whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable
practices, Fraud, Abuse, or mistake.
Point of Contact - Ombudsman, customer service center, call center, or other program that receives
Complaints from Medicaid Beneficiaries.
Presumptively Eligible Pregnant Women - This program allows staff at County Health
Departments (CHDs), Regional Perinatal Intensive Care Centers (RPICCs), and other qualified medical
facilities to make a presumptive determination of Medicaid eligibility for low-income pregnant women.
This presumptive determination allows a woman to access prenatal care while Department of Children
and Families eligibility staff make a regular determination of eligibility.
Prior Authorization - The act of authorizing specific services before they are rendered.
Protocols - Written guidelines or documentation outlining steps the Recipient, Subcontractors (if
any), and Transportation Providers must follow when handling a particular situation, resolving a
problem, or implementing a plan to provide Transportation Services. Also referred to as "policies and
proced u res. "
Quality - The degree to which a Recipient increases the likelihood of desired health outcomes of its
Medicaid Beneficiaries through its structural and operational characteristics and through the provision
of Transportation Services that are consistent with current professional knowledge.
Quality Improvement (QI) - The process of monitoring and assuring that the delivery of
Transportation Services are available, accessible, timely, and provided in sufficient quantity, of
acceptable Quality, within established standards of excellence, and appropriate for meeting the needs
of Medicaid Beneficiaries.
Quality Improvement Program (QIP) - The program designed to ensure the delivery of
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Transportation Services is appropriate, timely, accessible, and available.
Recipient - The entity that has entered into an Agreement with the Agency to provide Non-
Emergency Transportation coordination services to Medicaid Beneficiaries.
Road Calls - A call to repair or replace a vehicle while en route to pick up a Medicaid Beneficiary
and/or while transporting Medicaid Beneficiaries due to a mechanical or other failure, not the result of
an accident (e.g., air conditioning broke requiring a replacement vehicle to complete the driver's route,
replacing a flat tire, etc.)
Routine Trips - Medically Necessary Trips that are not urgent in nature (e.g., doctor's appointment
for an annual checkup).
Service Area - The designated geographical area within which the Recipient is authorized by the
Agreement to furnish Covered Services to Medicaid Beneficiaries.
Service Authorization - The Recipient's approval to render services. The process of authorization
must at least include a Medicaid Beneficiary's request for the provision of a service.
Span of Control - Information Systems and telecommunications capabilities that the Recipient itself
operates or for which it is otherwise legally responsible according to the terms and conditions of this
Agreement. The Recipient's Span of Control also includes Systems and telecommunications capabilities
outsourced/Subcontracted by the Recipient.
State - State of Florida.
State Holiday - Includes the following days: New Year's Day, Martin Luther King's Day, Memorial
Day, Independence Day, Labor Day, Veterans' Day, Thanksgiving Day and the Friday following, and
Christmas Day.
Subcontract - An agreement entered into by the Recipient and a subcontractor for provision of
administrative services on its behalf.
Subcontractor - Any person or entity with which the Recipient has contracted or delegated, by use
of a. Subcontract, some of its functions, services, or responsibilities for providing Transportation
Services under this Agreement.
Surface Mail - Mail delivery via land, sea, or air, rather than via electronic transmission.
.Surplus - Net worth, i.e., total assets minus total liabilities.
System Unavailability - As measured within the Recipient's Information Systems Span of Control,
when a system user does not get the complete, correct full-screen response to an input command
within three (3) minutes after depressing the "Enter" or other function key.
Systems - See Information Systems.
Temporary Assistance for Needy Families (TANF) - Public financial assistance provided to low-
income families.
Transportation - An appropriate means of conveyance furnished to a Medicaid Beneficiary to obtain
Medicaid compensable services.
Transportation Provider - A person or entity that is eligible to provide Medicaid Transportation
Services and has a contractual agreement with the Recipient or Subcontractor to provide Medicaid
Transportation Services. A Transportation Provider must be Licensed in accordance with the applicable
laws of the State in which it furnishes Transportation Services. A Su'bcontractor may act as a
Transportation Provider.
Transportation Provider Agreement - An agreement between the Recipient or Subcontractor and
a Transportation Provider as described above.
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Transportation Record - Documents corresponding to Transportation Services furnished by the
Recipient. The records may be on paper, magnetic material, film, or other media. In order to qualify as
a basis for reimbursement, the records must be dated, legible, and signed or otherwise attested to/ as
appropriate to the media.
Transportation Services - See "Covered Services."
Trip -Transport of a Medicaid Beneficiary one way, from pickup to destination for the purpose of
receiving Medicaid compensable services.
Urgent Care - Services for conditions, which, though not life-threatening, could result in serious
injury or disability unless medical attention is received (e.g., high fever, animal bites, fractures, severe
pain, etc.) or substantially restrict a Medicaid Beneficiary's activity (e.g., infectious illnesses, flu,
respiratory ailments, etc.), require Transportation Services to medical services in which advance
scheduling is not possible (e.g., sudden illness, an accident, or follow up laboratory work or tests), or
Hospital/facility inpatient or outpatient discharges after normal business hours.
Urgent Trip - A Trip relating to:
(1) Urgent Care;
(2) Hospital/facility inpatient and outpatient discharges; and
(3) Emergency room discharges.
Validation - The review of information, data, and procedures to determine the extent to which they
are accurate, reliable, free from bias, and in accord with standards for data collection and analysis.
Violation - A determination by the Agency, in its sole discretion, that the Recipient, or one of the
Recipient's Subcontractors or Transportation Providers, failed to act as specified in this Agreement or
applicable statutes, rules, or regulations governing Medicaid Vendors. The Agency shall consider each
day that an ongoing Violation continues, for the purposes of this Agreement, to be a separate Violation.
In addition, the Agency shall consider each instance of failing to furnish necessary and/or required
Transportation Services to Medicaid Beneficiaries, for purposes of this Agreement, to be a separate
Violation. As well, the Agency shall consider each day that the Recipient, or one of the Recipient's
Subcontractors or Transportation Providers, fails to furnish necessary and/or required Transportation
Services to Medicaid Beneficiaries, for purposes of this Agreement, to be a separate Violation.
Will Call - A scheduled Trip that could not be fulfilled within the timeframes of this Agreement leading
to the Transportation Provider making an unscheduled Medicaid compensable Trip. Example - a
Medicaid Beneficiary notifies the Transportation Provider that a doctor is running later than originally
scheduled and asks to reschedule his or her Trip to his or her destination. When the Medicaid
Beneficiary notifies the Transportation Provider that he or she is ready for pick up, the Transportation
Provider puts in a Will Call pick up order to its driver to pick up the Medicaid Beneficiary and take him
or her to his or her destination.
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B. Acronyms
AHCA -Agency for Health Care Administration
ALF - Assisted Living Facility
ALS - Advanced Life Support
BLS - Basic Life Support
CAP - Corrective Action Plan
CFR - Code of Federal Regulations
CTAA - Community Transportation Association of America
CTC - Community Transportation Coordinator
CTD - Commission for the Transportation Disadvantaged
DCF - Department of Children & Families
DHHS - United States Department of Health & Human Services
DJJ - Department of Juvenile Justice
EDI - Electronic Data Interchange
EQR - External Quality Review _
EQRO - External Quality Review Organization
FAC - Florida Administrative Code
FTE - Full Time Equivalent Position
HCSS - Home and Community Based Services Waiver
HIPAA - Health Insurance Portability & Accountability Act
LCB - Local Coordinating Board
LEIE - List of Excluded Individuals & Entities
MCO - Managed Care Organization
MFCU - Medicaid Fraud Control Unit of the Florida Attorney General's Office
MPI - Bureau of Medicaid. Program Integrity, a part of the Agency
NET - Non-Emergency Transportation services
ODBC - Open Database Connectivity
PM - Performance Measure
PRTS - Purchased Residential Treatment Services
QI - Quality Improvement
QIP - Quality Improvement Program
RHC - Rural Health Clinic
SAMH - Substance Abuse & Mental Health District
SFTP - Secure File Transfer Protocol
SOBRA - Sixth Omnibus Budget Reconciliation Act
SQL - Structured Query Language
5S1 - Supplemental Security Income
UM - .Utilization Management
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