Item C14
MONROE COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: October 18-19. 2000
Bulk Item: Yes X No
Division: Public Safety
Department: Public Safety
AGENDA ITEM WORDING: Approval for Mayor to execute Medicare EDI Enrollment Form in
regards to ambulance billing services
ITEM BACKGROUND: At the August 16,2000 meeting, the Board approved an agreement between
Monroe County and Advanced Data Processing, Inc. for ambulance billing and related professional
services. The attached Medicare EDI Enrollment Form authorizes Advanced Data Processing, Inc. to
electronically transfer run reports using Monroe County's Medicare Provider number.
PREVIOUS RELEVANT BOCC ACTION: See above
STAFF RECOMMENDATION: Approval
TOTAL COST: 0.00
COST TO COUNTY: 0.00
REVENUE PRODUCING: Yes
BUDGETED: Yes
No
No
N/A
DOCUMENTATION: Included: X To Follow: _ Not Required:
APPROVED BY: County Attorney YES
DIVISION DIRECTOR APPROVAL:
DISPOSITION:
Agenda Item #:
/ -elL!
GENERAL COl\lIPLETION INSTRUCTIONS FOR
"EDI ENROLL.MENT FORlVI"
Page 1-2 of 3
Section A-B: Each provider, supplier or P A group who is applying to submit electronic claims or replacing
existing forms should ensure they read and agree to the provisions in this section of the document prior to signing.
Page J of J
Section C: TInS SECTION MUST BE COMPLETED (each field is listed in the order as it appears on
the form)
PROVIDER NAME: Name of provider, supplier or PA group should be listed (enrollment forms forPA
groups should always have the PAgroup name listed in the Provider's Name section).
TITLE: Indicate the title of the provider, supplier or P A group listed in the Provider's Name section.
ADDRESS: The physical address where services are performed must be listed. If you recently changed
your address, do not submit your enrollment form until the change has been made with Medicare B Registration.
CITY /ST A TE/ZlP: Indicate the city/state/zip for the provider, supplier or P A group.
BY: The signature of the person completing the enrollment form should be listed.
TITLE: Title of person completing enrollment form (e.g. Office Manager, NID, Billing Coordinator, etc.).
DATE: Date enrollment form was completed.
PHYSICIAN/SUPPLIERlPA GROUPIHOSPITAL ADMINISTRATOR SIGNATURE: Provider'
signature, owner of supplier site (e.g., IPL, ACS, etc.) signature of president or office manager signature for PA
groups is required.
BILLING SERVICE: Name of company. If you are using a billing service to submit your claims
electronically, indicate the name of the company.
CLEARINGHOUSE: Name of company. If you are using a clearinghouse to submit your claims
electronically, indicate the name of the company.
SENDER NUMBER: Indicate the sender number you currently use to bill electronically to Medicare if
already established. If you are adding a provider to your existing EMC sender location indicate your sender number.
If you currently bill paper claims this field should be left blank.
CONTACT PERSON: Name of the person in the provider's office to speak with regarding application or
claims inquiries.
TELEPHONE NUMBER: Telephone number (with area code) of the contact person.
:MEDICARE B PHYSICIAN/SUPPLIERIP A GROUP PROVIDER NUJM:BER: Provider number
used to bill Medicare B; if provider is a P A group or facility list the group or facility number.
MEDICARE A PROVIDER NUMBER: This is for Medicare Part A provider's only (hospitals, CORF,
etc.) Hospitals billing for Medicare Part B services to Blue Cross Blue Shield of Florida (in Jacksonville) need to
indicate the provider number in the Medicare B Provider Number section.
EDI Enrollment Form
The provider agrees to the following provisions for submitting Medicare claims electronically to HCF A or to
HCF A's contractors.
A The Provider Agrees:
1. That it will be responsible for all Medicare claims submitted to HCF A by itself, its employees, or
its agents.
2. That it will not disclose any infoxmation concerning a Medicare beneficiary to any other person or
organization, except HCF A and/or its contractors, without the express written pennission of the
Medicare beneficiary or hislher parent or legal guardian, or where required for the care and treatment of
a beneficiary who is unable to provide written consent, or to bill insurance primary or supplementary to
Medicare, or as required by State or Federal law.
3. That it will submit claims only on behalf of those Medicare beneficiaries who have given their
written authorization to do so, and to certify that required beneficiary signatures, or legally authorized
signatures on behalf of beneficiaries, are on file.
4. That it will ensure that every electronic entry can be readily associated and identified with an
original source document. Each source document must reflect the following information.
. Beneficiary's name,
. Beneficiary's health insurance claim number,
. Date (s) of service,
. Diagnosis/nature of illness, and
. Procedure/service perfoxmed.
5. That the Secretary of Health and Human Services or hislher designee and/or the contractor has the
right to audit and confmn information submitted by the provider and shall have access to all original
source documents and medical records related to the provider's submissions, including the
beneficiary's authorization and signature. All incorrect payments that are discovered as a result of such
an audit shall be adjusted according to the applicable provisions of the Social Security Act, Federal
Regulations, and HCF A guidelines.
6. That it will ensure that all claims for Medicare primary payment have been developed for other
insurance involvement and that Medicare is the primary payer.
7. That it will submit claims that are accurate, complete, and truthful.
8. That it will retain all original source documentation and medical records pertaining to any such
particular Medicare claim for a period of at least 6 years, 3 months after the bill is paid.
9. That it will affIx the HCF A-assigned unique identifier number of the provider on each claim
electronically transmitted to the contractor.
10. That the HCF A-assigned unique identifier number constitutes the provider's legal electronic
signature and constitutes an assurance by the provider that services were performed as billed.
I of 3
11. That it will use sufficient security procedures to ensure that all transmissions of documents are
authorized and protect all beneficiary-specific data from improper access.
12. That it will acknowledge that all claims will be paid from Federal funds, that the submission of
such claims is a claim for payment under the Medicare program, and that anyone who misrepresents or
falsifies or causes to be misrepresented or falsified any record or other information relating to that
claim that is required pursuant to this Agreement may, upon conviction, be subject to a fine and/or
imprisonment under applicable F ederallaw.
13. That it will establish and maintain procedures and controls so that information concerning
Medicare beneficiaries, or any information obtained from HCF A or its contractor, shall not be used by
agents, officers, or employees of the billing service e.,<cept as provided by the contractor (in accordance
with Sll06(a) of the Act).
14. That it will research and correct claim discrepancies.
15. That it will notify the contractor or the HCFA within 2 business days if any transmitted data are
received in an unintelligible or garbled form.
B. The Health Care FinancinlZ Admintstration will:
1. Transmit to the provider an acknowledgment of claim receipt.
? AffL'< the intermediary/carrier number, as its electronic signature, on each remittance advice sent to
the provider.
3. Ensure that payments to providers are timely in accordance with HCF A's policies.
4. Ensure that no contractor may require the provider to purchase any or all electronic services from
the contractor or from any subsidiary of the contractor or from any company for which the contractor
has an interest The contractor will make alternative means available to any electronic biller to obtain
such services.
5. Ensure that all Medicare electronic billers have equal access to any services that HCF A requires
Medicare contractors to make available to providers or their billing services regardless of the electronic
billing technique or service they choose. Equal access will be granted to any services the contractor
sells directly, indirectly, or by arrangement.
6. Notify the provider within 2 business days if any transmitted data are received in an unintelligible
or garbled form.
NOTICE:
F ederallaw shall govern both the interpretation of this document and the appropriate jurisdiction and venue for
appealing any fmal decision made by HCF A under this document.
This document shall become effeytive when signed by the provider. The responsibilities and obligations contained in
this document will remain in effect as long as Medicare claims are submitted to HCF A or the contractor. Either party
may terminate this arrangement by giving the other party (30) days written notice of its intent to terminate. In the
event that the notice is mailed., the written notice of termination shall be deemed to have been given upon the date of
mailing, as established by the postmark or other appropriate evidence of transmittal.
20f3
Wednesday 06 of Sep 2000, BCBSFL_JacKsonville ->Billing/lns Recovery Page 5 of 6
C. Silm3ture:
I am authorized to sign this document on behalf of the indicated party and I have read and agreed to the foregoing provisions and
acknowledge same by signing below:
Provider's Name
Monroe County EMS
Title
Address
490 63rd Street, Suite 140
City/State/Zip
Marathon, FL 33050
By
x
Shirley Freeman
Title
Mayor
Date
==========~==================================================================================
PLEASE PROVIDE THE FOLLOWING MEDICARE INFORMATION
x
Sender Number:
N Do d.-9
Po-\..) \ \= ro..C\ 7..do..5
305 - q 4 s- ll'OO
J:i!1.Billing Service Name of Company
M ,,0... (\ Co e.d Do.. -k pro c.. e.. ~ \ ("\ Co....
Provider/SuppliertPA Group/Hosp. Administrator Signature
o Clearinghouse Name of Company
Contact Person:
Telephone Number:
Type of Claim: 0 Medicare Part A 4 digit Provider Number: 10
)( Medicare Part B
Physician/Supplier/PA Group
Provider Number:
A 04gY.
Mailing Address:
Medicare EDI
PO Box 44071 - 7C
Jacksonville, FL 32231 .4071
Attention:
Physical Address:
Medicare EDI
532 Riverside Ave. 7C
J::.clc;orl':ille, FL 32202-4918
EMC Agreement Analyst
5