5. 07/21/2010 Agreement
DANNY L. KOLHAGE
CLERK OF THE CIRCUIT COURT
DA TE:
July 28, 2010
TO:
Trish Barker, Senior Administrator
Bayshore Manor
Pamela G. Hanc~
FROM:
At the July 21, 2010, Board of County Commissioner's meeting the Board granted
approval and authorized execution of the Medicaid Provider Agreement between Monroe
County and the Agency for Health Care Administration for Monroe County Bayshore Manor to
re-enroll in a Provider Agreement for participation in the Title XIX Institutional Florida
Medicaid Program.
Enclosed are two duplicate originals 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!
INSTITUTIONAL
MEDICAID PROVIDER AGREEMENT
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The Provider agrees to participate in the Florida Medicaid program under the following terms and
conditions:
(1) Discrimination. The parties agree that the Agency for Health Care Administration (AHCA) may make
payments for medical assistance and related services rendered to Medicaid recipients only to a person or
entity who has a provider agreement in effect with AHCA; who is performing services or supplying goods
in accordance with federal, state, and local law; and who agrees that no person shall, on the grounds of
sex, handicap, race, color, national origin, other insurance, or for any other reason, be subjected to
discrimination under any program or activity for which the provider receives payment from AHCA.
(2) Quality of Service. The provider agrees that services or goods billed to the Medicaid program must be
medically necessary, of a quality comparable to those furnished by the provider's peers, and within the
parameters permitted by the provider's license or certification. The provider further agrees to bill only for
the services performed within the specialty or specialties designated in the provider application on file
with AHCA. The provider must deliver the services or goods to eligible Medicaid recipients to receive
payment from AHCA.
(3) Comoliance. The provider agrees to comply with local, state, and federal laws, as well as rules,
regulations, and statements of policy applicable to the Medicaid program, including the Medicaid Provider
Handbooks issued by AHCA.
(4) Term and sianatures. The parties agree that this is a voluntary agreement between AHCA and the
provider, in which the provider agrees to furnish services or goods to Medicaid recipients. Provided that
all requirements for enrollment are met and remain in effect, this agreement shall remain in effect for
three (3) years from the effective date of the provider's eligibility unless otherwise terminated. This
agreement is renewable only by mutual consent. The provider understands and agrees that no AHCA
signature is required to make this agreement valid and enforceable. This agreement shall be accepted
and entered into by AHCA upon the assignment of a provider number and effective date as provided for
herein.
(5) Provider Resoonsibilities. The Medicaid provider shall:
(a) Possess at the time of the signing of the provider agreement, and maintain in good standing
throughout the period of the agreement's effectiveness, a valid professional, occupational, facility or other
license appropriate to the services or goods provided, as required by law.
(b) Keep, maintain, and make available in a systematic and orderly manner all medical and
Medicaid-related records as AHCA requires for a period of at least five (5) years.
(c) Safeguard the use and disclosure of information pertaining to current or former Medicaid recipients as
required by law.
(d) Send, upon request or as required by applicable handbooks and at the provider's expense, legible
copies of all Medicaid-related information to authorized state and federal employees, including their
agents. The provider shall give state and federal employees, including their agents, access to all
Medicaid patient records and to other information that is inseparable from Medicaid-related records.
(e) Bill other insurers and third parties, including the Medicare program, before billing the Medicaid
program, if the recipient is eligible for payment for health care or related services from another insurer or
person.
(f) Refund any moneys received from the Medicaid program in error or in excess of the amount to which
the provider isentitled within 90 days of receipt.
(g) Be liable for and indemnify, defend, and hold AHCA harmless from all claims, suits, judgments, or
damages, including court costs and attorney's fees, arising out of the negligence or omissions of the
provider in the course of providing services to a recipient or a person believed to be a recipient to the
extent allowed by in and accordance with section 768.28, F.S. (2001), and any successor legislation.
(h) Accept Medicaid payment as payment in full, and not bill or collect from the recipient or the recipient's
responsible party any additional amount except to the extent AHCA permits or requires, co-payments,
coinsurance, or deductibles will recipients' pay for the services or goods provided. This includes situations
in which the provider's Medicare coinsurance claims are denied in accordance with Medicaid's payment.
MPA Institutional Hevised February 2007
(i) Submit claims to AHCA electronically and to abide by the terms of the Electronic Claims Submission
Agreement.
U) Receive payment from AHCA by Electronic Funds Transfer (EFT). In the event that AHCA erroneously
deposits funds to the provider's account, then the provider agrees that AHCA may withdraw the funds
from the account.
(k) Comply with all of the requirements of Section 6032 (Employee Education About False Claims
Recovery) of the Deficit Reduction Act of 2005, if the provider receives or earns five million dollars or
greater annually under the State plan.
(6) AHCA Responsibilities. AHCA:
(a) Is required to make timely payment at the established rate for services or goods furnished to a
recipient by the provider upon receipt of a properly completed claim.
(b) Will not seek repayment from the provider in any instance in which the Medicaid overpayment is
attributable solely to error in the state's determination of eligibility of a recipient.
(7) Termination For Convenience. This agreement is terminable upon thirty (30) days written notice with
or without cause by either party.
(8) Ownership. The provider agrees to give AHCA sixty (60) days written notice before making any
change in ownership of the entity named in the provider agreement as the provider. The provider is
required to maintain and make available to AHCA Medicaid-related records that relate to the sale or
transfer of the business interest, practice, or facility in the same manner as though the sale or transaction
had not taken place, unless the provider enters into an agreement with the purchaser of the business
interest, practice, or facility to fulfill this requirement. Nursing facilities have the option to assign this
agreement to the new provider as a result of sale, lease, or any other change in operational ownership
subject to all terms and conditions under which the agreement was originally issued. In the event of a
change in Hospital ownership, the new provider agrees to assume all liabilities due from previous
providers to the agency, regardless of when the liabilities are identified, in order to participate in the
Medicaid program.
(9) Complete Information. The provider is required to furnish true and complete statements and
information to AHCA before signing the provider agreement. The provider is obligated to inform AHCA in
writing of any change in the statements and information prior to the change. The filing of a materially
incomplete, misleading or false application will make the application and agreement voidable at the
AHCA's option and is sufficient cause immediate termination of the provider from the Medicaid program
and/or revocation of the provider's number.
(10) Interpretation. When interpreting this agreement, it shall be neither construed against either party nor
considered which party prepared the agreement.
(11) Governing Law. The parties consent to governance by and interpretation of their agreement in
accordance with the State of Florida's laws.
(12) Amendment. This agreement, application and supporting documents constitute the full and entire
agreement and understanding between the parties with respect to their relationship. No amendment is
effective unless it is in writing and signed by each party.
(13) Severability. If one or more of the provisions contained in this agreement or application are declared
invalid, then the other provisions remain valid.
MPA Institutional Revised February 2007
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(14) Aareement Retention. The parties agree that AHCA may only retain the signature page of this
agreement, and that a copy of this standard provider agreement is maintained by the Director of
Medicaid, or his designee, and reproduced as a duplicate original for any purpose and usable as
evidence in any legal proceeding.
(15) Funding. This contract is contingent upon the availability of funds.
(16) Assianability, The parties agree that neither may assign their rights under this agreement without the
express written consent of the other.
THE PARTIES CONCUR THAT THIS AGREEMENT IS A LEGAL AND BINDING DOCUMENT AND IS
FULLY ENFORCEABLE IN A COURT OF COMPETENT JURISDICTION.
THE SIGNATORY REPRESENTS THAT HE OR SHE HAS READ THE AGREEMENT, UNDERSTANDS
IT, AND IS AUTHORIZED TO EXECUTE IT ON BEHALF OF HIS OR HER RESPECTIVE PRINCIPALS.
IN WITNESS WHEREOF, the undersigned representative of the above executed this agreement under
the penalty of perjury and now affirms that the foregoing is true and correct.
Sylvia J. Murphy
(legibly print name of signatory)
Mayor
Title
~~ 07/21/2010
Si ature Date
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Please Complete The Following Information:
Provider's Name:
MONROE COUNTY BAYSHORE MANOR
DBA Name:
Tax Identification Number:
596000749
National Provider Identifier:
Florida Medicaid Identification Number: 1401599
(For new applicants the Medicaid ID will be supplied by the fiscal agent upon approval of the
application. )
Taxonomy Code: (Optional)
Effective Date of This Agreement:
Termination Date of This Agreement:
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