1. 08/13/1996 Agreement 'WUM
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Dannp i. "(gage
BRANCH OFFICE CLERK OF THE CIRCUIT COURT BRANCH OFFICE
3117 OVERSEAS HIGHWAY MONROE COUNTY 88820 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050 500 WHITEHEAD STREET PLANTATION KEY, FLORIDA 33070
TEL. (305)289-6027 KEY WEST, FLORIDA 33040 TEL. (305) 852-7145
TEL. (305)292-3550
MEMORANDUM
TO: Louis La1'mre
Director of Social Services at
FROM: Ruth Ann Jantzen, Deputy Clerk 41a�'
DATE: August 27, 1996
At the August 13, 1996 County Commission Meeting, the Board granted approval
and authorized execution of a Provider Re-enrollment Request Form and a Medicaid
Provider Agreement between Monroe County and State of Florida Agency for Health
Care Administration.
Enclosed please find a fully executed duplicate original of the above for your
handling.
If you have any questions on the above, please do not hesitate to contact this
office.
cc: County Attorney
Finance
County Administrator, w/o document
Community Services Director, w/o document
File
' DATE 06/08/96
•
r PROVIDER REENROLLMENT REQUEST FORM
LISTED BELOW ARE EXCERPTS FROM THE MEDICAID PROVIDER FILE FOR YOUR PROVIDER
NUMBER. PLEASE REVIEW AND CHANGE IT AS NECESSARY. PROVIDE ACCURATE
INFORMATION FOR EACH QUESTION. DRAW A LINE THROUGH THE INCORRECT ITEM AND
WRITE THE CORRECT INFORMATION IN RED INK.
G MEDICAID PROVIDER NUMBER 0881511 00
a MEDICARE PROVIDER NUMBER
MONROE CO BRD OF CO COMM
II PROVIDER NAME
It DBA OF APPLICABLE)
A PROVIDER BUSINESS ADDRESS TRANSPORTATION PROGRAM
5100 COLLEGE RD
U CITY KEY WEST STATE FL ZIP 33040-0000
R PROVIDER BUSINESS TELEPHONE NUMBER 13051 294-8468
U PROVIDER PAY-TO ADDRESS TRANSPORTATION PROGRAM
5100 COLLEGE RD
11 CITY KEY WEST STATE FL ZIP 34040-0000
12 PROVIDER TAX I.D. NUMBER 59-6000749
R GROUP AFFILIATION (GROUP PROVIDER NUMBERS WITH WHICH YOU ARE AFFILIATED)
p SPECIALTY CODES
a PROVIDER TYPE 44 PRACTICE TYPE 30
ElSIGNATURE Sly • Ad cr.A.�T1Q atta.t. DATE AllRUS C 13 , 1 '96
R TITLE Mayor/ChairmaiY
YOUR SIGNATURE CERTIFIES THAT THIS INFORMATION, INCLUDING UPDATES, IS
_ i ACCURATE. FAILURE TO COMPLETE THIS FORM AND RETURN TO UNISYS WILL RESULT
!. '_ 1 .1 IN TERMINATION OF YOUR PROVIDER NUMBER THE BACK PORTION OF THIS DOCUMENT
le, MUST ALSO BE COMPLETED.
APPROVED AS TO FOR
(SEAL) ANO.LEGAL SUFFICENP 1
ATTEST: DANNY L. KOIHAGE,_CLERK C !�
L C. U' NNE A./6IU ON
BY Iw �'yN`. DATE 7/ )/(��'
DEPUTY LERK 000
FISCAL
AGENT USE
1. • 1. Please Identify all officers, directors, and principle owners in your business15% or more). List their
names and social security numbers on a separate sheet of your company letterhead. The latter must
be signed and dated by the chief officer of the business. Providers who submit a HCFA 1513 for
enrollment purposes are exempt from this request).
2. Have any of the people listed in question 1 ever:
2a,1:1 a. Been convicted of a felony, pled nolo contendere or entered into a pre-trial intervention program?
YES NO
2b.0 b. Had any disciplinary action taken against any business or professional license they held in any state?
YES NO
If "YES", what action was taken?
By whom was the action taken?
Date
2c.0 c. Personally been denied enrollment, suspended or excluded from Medicaid or Medicare in any state
or been employed by a corporation, business or professional association that has been suspended or
excluded from Medicaid or Medicare in any state? YES NO
3, 0 3. On a separate sheet, provide the following:
a. The street address in Florida of the location from which the Medicaid services are provided.
b. The name of the custodian of records; and
Pharmacy providers must submit the name of the primary pharmacy manager and the legal name and
trade name, if different.
NOTE:Applicant agrees that all official notices will be sent to the mailing address indicated.
4, 0 4. For group physicians(M.D. and D.O.), is more than 50% of your group practice owned by
non physicians?YES NO If yes, a surety bond is required.
N /A
Certification
For the purpose of establishing eligibility to receive direct payment for services rendered to recipients of the
Florida Medicaid Program, I understand that the filing of materially incomplete or false information with this
emrollment request is sufficient cause for termination from the Florida Medicaid Program. I understand that it is my
responsibility to notify Medicaid's fiscal agent of any change to the information on this application including but not
limited to, address, group affiliation, change of ownership or tax identification/number. /J ,._{��'+
SHIRLEY FREEMAN q\ ( iiht( ,J • d�
Name of Provider or Authorized Agent /^�I�(./) �S'. Signa are of Provid or Authorized Agent
BOARD OF COUNTY COMMISSIONERS \� ��/3�9�
Mavor/Chairman
TITLE (' DATE
•� O
Mail this application and all requiredAPPROVED AS T FORM
papa4�r AND AL SUf ?c Yf
l
Unisys. Provider Enrollment (SEAL) NNE A. UTf N
P.O. Box 7070 ATTEST: DANNY L KOIHAGE, OUR ATE //�'
Tallahassee, Florida 32314-7070 / /`
BY
DEPU CLERK
Vat?.
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s
3 '-t MEDICAID PROVIDER AGREEMENT
The Provider agrees to participate in the Florida Medicaid program under the following terms and conditions:
(1) Discrimination. The parties agree that the Agency for Health Care Administration (Agency) 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 the Agency, 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 the Agency.
(2) Quality of SPrvicP. The provider agrees to provide medically necessary services or goods of not less than the scope
and quality it provides to the general public. 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 the Agency. The services
or goods must have been actually provided to eligible Medicaid recipients by the provider prior to submitting the claim.
(3) Compliance. The provider agrees to comply with all local, state and federal laws, rules, regulations, licensure laws,
Medicaid bulletins, manuals, handbooks and Statements of Policy as they may be amended from time to time.
(4)Term and signatures. The parties agree that this is a voluntary agreement between the Agency and the provider, in
which the provider agrees to furnish services or goods to Medicaid recipients. This provider agreement shall become
effective the date the provider's application is received by the state or its fiscal agent. It shall remain in effect until July 1,
1999, unless otherwise terminated. This agreement shall be renewable only by mutual consent. The provider
understands and agrees that no Agency signature is required to make this Agreement valid and enforcable.
(5) Provider Responsibilities. 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 agreements effectiveness, a valid professional, occupational, facility or other license appropriate to the services or
goods being provided, if required by the state or locality in which the provider is located, or the federal government.
(b) Keep and maintain in a systematic and orderly manner all medical and Medicaid related records as the Agency may
require and as it determines necessary; make available for state and federal audits for five years, complete and accurate
medical, business, and fiscal records that fully justify and disclose the extent of the goods and services rendered and
billings made under the Medicaid program. The provider agrees that only contemporaneously made records of goods and
services provided will be admissible in evidence in any proceeding relating to payment for or provision of services for the
purpose of supporting any claim submitted to or paid by the Medicaid program.
(c) Safeguard the use and disclosure of information pertaining to current or former Medicaid recipients and comply with
all state and federal laws pertaining to confidentiality of patient information.
(d) Furnish to the Agency, upon request, all information regarding any payments claimed for providing goods or services.
The provider agrees to provide immediate access to authorized persons (including but not limited to state and federal
employees, auditors and investigators)to all Medicaid-related information, which may be in the form of records, logs,
documents, or computer files, and all other information pertaining to services or goods billed to the Medicaid program.
This shall include access to all patient records and other provider information if the provider cannot easily separate records
for Medicaid patients from other 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)Wthin 90 days, refund any moneys received in error or in excess of the amount to which the provider is entitled from
the Medicaid program.
MPA Revised 3/96
(g)Be liable for and indemnify, defend, and hold the Agency harmless from all claims, suits,judgments, or damages,
including court costs and attorney's fees, arising out ci the negligence, omissions or commissions of the provider in the
course of providing services to a recipient or a person believed to be a recipient. The Agency may not seek
indemnification for any occurrence for which it is solely at fault.
(h)Accept Medicaid payment as payment in full, and not bill or collect from the recipient or the recipient's responsible
party any additional amount except, and only to the extent the Agency permits or requires, co-payments, coinsurance, or
deductibles to be paid by the recipient for the services or goods provided. This includes situations when the provider's
Medicare coinsurance claims are denied in accordance with Medicaid's payment.
(i)Assure that the signature on the claim form submitted to the Agency for payment is appropriate for authorization.
Persons authorized to submit Medicaid claims on behalf of the provider shall be limited to the provider, the provider's
employees, or an authorized billing agent. The provider shall be liable for all overpayments for any reason and pay to the
Agency any fine or overpayment imposed by the Agency or a court of competent jurisdiction. Provider agrees to pay
interest at 12% per annum on any fine or repayment amount that remains unpaid from the date of any final order
requiring payment to the Agency.
(j) Provide information for each officer, director, manager and person with 5%or more ownership interest in the provider
concerning any conviction, regardless of adjudication, for any felony under state or federal law and any violation, fine,
suspension, termination, or other administrative action taken under the Medicaid or Medicare programs or laws, rules, or
regulations of this or any other state or the federal government.
(k) Provider agrees to prominently display, in such a manner as to be visible to all of Provider's agents and employees in
each location where provider delivers or bills for Medicaid services, all information concerning the Medicaid program that
the Agency sends to Provider for display.
(6)Agency Responsibilities. The Agency:
(a)Will make timely payment at the established rate for medically necessary services or goods furnished to an eligible
recipient by the provider upon receipt of a properly completed claim form. This contract is contingent upon the availability
of funds. The established rate of payment is subject to change based upon legislative directive or funding.
(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.
(c)Will require a bond, letter of credit or other collateral from the following providers, unless they have been a Medicaid
provider for at least one(1)year and no sanction has been imposed by the Agency:
1. Group practices(provider types 25 &26; practice type 35) (if more than 50% is owned by
non physicians)
2. Transportation companies(provider types 41, 43 &47)
3. Home Health companies(provider type 65 or 67)
4. Durable Medical Equipment companies(provider type 90 or 67)
Government owned or operated entities are exempted from these bonding requirements.
(d)The bond, letter of credit or other collateral referred to in paragraph (c)above will be in place for a period of 12
months from the date that the provider agreement becomes effective and will be in the amount of fifty thousand dollars
($50,000.00). The form of the bond, letter of creditor other collateral must be acceptable to the Agency. The surety
company must be licensed to transact business in Florida.
(7)Termination and Equitable Relief. This agreement may be terminated,without cause, upon thirty (30) days written
notice by either party. The Agency may terminate this agreement for cause and may apply for and obtain injunctive or
other relief in the Circuit Court of Leon County, Florida to enforce this provision or any other provisions of this agreement.
MPA Revised 3/96
- (8)Ownership. The provider agrees to give the Agency sixty (60)days written notice before making any change in
ownership of the entity named in the provider agreement as the provider. A Medicaid provider agreement shall be
terminated in the event of a change of ownership of any facility, association, partnership, or interest or practice that
substantially constitutes the entity named as the provider in the provider agreement, or sells or transfers a facility that is of
substantial importance to the entity named as the provider in the provider agreement. The provider is required to maintain
and make available to the Agency Medicaid-related records that relate to the sale or transfer of the business interest,
practice, or facility in the same manner as though the sale or transaction had not taken place, unless the provider enters
into an agreement with the purchaser of the business interest, practice, or facility to fulfill this requirement.
(9) Complete Information.All statements and information furnished by the prospective provider for background
information before signing the provider agreement shall be true and complete. The filing of a materially incomplete,
misleading or false application will make the application and agreement voidable at the option of the Agency and is
sufficient cause for immediate termination of the provider from the Medicaid program and/or revocation of the provider
number.
(10) Repayment. Failure of any provider to adhere to an agreed upon repayment schedule shall constitute the provider's
authorization for the agency,without further notice, to withhold the total amount due under the repayment schedule from
any moneys due and owing to the provider for any claims which have been or will be submitted and will also constitute
sufficient cause for immediate suspension or termination from the Medicaid program and/or revocation of the provider
number.
(11) Interpretation. This Agreement shall not be construed against either party on the basis of this Agreement having
been prepared by one of the parties.
(12) Governing Law and Statistical Proof.This Agreement shall be governed by and construed in accordance with the
laws of the State of Florida and the United States. The provider agrees that any alleged overpayment under this
agreement may be proven by statistical methods and upon a prima fade showing of correctness by the Agency, the
burden of proof shifts to the provider.
13)-Venue:Venue for all actions, including federal actions, pursuant to this agreement lies in Leon County, Florida.
(14) Jurisdiction. The parties expressly agree that there is no property right in and to a Medicaid provider number and
that:
(a)The appropriate circuit or county court in Leon County, Florida shall have jurisdiction of all equitable matters.
(b)The Agency shall have the discretion to resolve all other matters by informal hearing.
(c)The Agency shall have the sole discretion to remove any case to the Division of Administrative Hearings for a formal
hearing.
(d) In the event of concurrent or over-lapping jurisdiction, the Agency shall determine the proper forum.
(15)Amendment. This Agreement,Application and the other documents being executed and delivered pursuant hereto
constitute the full and entire agreement and understanding between the parties hereto with respect to the subject matter
hereof. No amendment shall be effective unless it is in writing and signed by each party.
(16)Titles. The titles of the provisions of this Agreement are for convenience or reference only and are not to be
considered in construing this Agreement.
(17) Severability. If one or more of the provisions contained in this Agreement or Application shall be invalid, illegal or
unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or
impaired.
•
(18)Additional Assurances.The parties agree to execute and deliver such other documents as are contemplated
hereby.
(19)Assignability. The Provider number is the property of the Agency and the provider may not assign its rights or
obligations under the number or this Agreement without the express written consent of the Agency.
(20)Waiver. The waiver by either party of any breach of any covenant or condition of this Agreement shall not be
construed as a waiver of any subsequent breach of any covenant or condition contained in this Agreement.
MPA Revised 3/96
' • (21)Agreement Retention. The parties agree that the Agency may only retain the signature page of this agreement, and
that a copy of this standard provider agreement will be maintained by the Director of Medicaid, or his designee, and may
be reproduced as a duplicate original for any legal purpose and may also be entered into evidence as a business record.
THE PROVIDER AGREES THAT THIS AGREEMENT SHALL MERGE WITH AND BECOME A PART OF THE
PROVIDER APPLICATION AND IS SIGNED UNDER THE PENALTIES OF PERJURY. THE PARTIES AGREE THAT
THIS AGREEMENT IS A LEGAL AND BINDING DOCUMENT AND IS FULLY ENFORCEABLE IN A COURT OF
COMPETENT JURISDICTION. THE SIGNATORIES HERETO REPRESENT AND WARRANT THAT THEY HAVE READ
THE AGREEMENT, UNDERSTAND IT AND ARE AUTHORIZED TO EXECUTE IT ON BEHALF OF THEIR RESPECTIVE
PRINCIPALS OR CO-OWNERS. THIS AGREEMENT BECOMES NULL AND VOID UPON TRANSFER OF ASSETS,
CHANGE OF OWNERSHIP OR UPON DISCOVERY BY THE AGENCY OF THE SUBMISSION OF A MATERIALLY
INCOMPLETE, MISLEADING OR FALSE PROVIDER APPLICATION UNLESS SUBSEQUENTLY RATIFIED OR
APPROVED BY THE AGENCY.
ALL PRINCIPALS, PARTNERS AND SHAREHOLDERS HAVING AN OWNERSHIP INTEREST OF FIVE PERCENT(5%)
OR GREATER ARE REQUIRED TO SIGN THIS AGREEMENT. FAILURE TO DO SO WILL MAKE THIS APPLICATION,
AGREEMENT AND PROVIDER NUMBER VOIDABLE BY THE AGENCY.
FOR OFFICE USE ONLY
The provider's name is: _ .
The facility's name is: .
The provider number is: .
!N.W!TNESS WHEREOF, the undersigned have caused this Agreement to be duly executed under the penalties of
perjury, swear or affirm that the foregoing i5 trt*eOapd5p� BOARD OF COUNTY COMMISSIONERS
MUN n u0514444 ha elAt ^^^ra"to 11I13ItG
Signature of Provider Date Signatde of Provider Date
SHIRLEY/ FREEMAN Mayor
(legibly print the above signature) Title (legibly print the above signature Title
�.co
Of'
Qf ii.. d
(USE ADDITIONAL PAGES IF NECESSARY)
APPROVED AS TO F•' / (SEAL/
AN• - AL SUFFICt 1 ATTEST: DANNY L. KOLNAGE, CLERK
By .41Aetna'NNE�A.y1UTTON BY
DATE � --� DEPU CLE0.1✓
MPA Revised 3/96