Item C17
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 Agency for Health Care Administration
Electronic Claims Submission Agreement 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 Agency for Health Care Administration Electronic Claims Submission Agreement is
required to authorize Advanced Data Processing, Inc., as billing agent, to submit electronic claims for
reimbursement by Florida Medicaid on behalf of Monroe County for ambulance services.
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
James R. "Reggie" Paros
DOCUMENTATION: Included: X To Follow: _ Not Required:
APPROVED BY: County Attorney YES
DIVISION DIRECTOR APPROVAL:
DISPOSITION:
Agenda Item #:
/-C'/7
.
Agency for Health Care.. Administration
Electronic Claims. Submission. Agreement
This form must be completed by any provider who plans to submit claims
electronically for reimbursement by Florida Medicaid.
I, M 0(\ roe. (!Olin ~f-~p~esented by
(Provider Name) (Representative's Name)
understand and agree to the following:
1. Payment of claims will be from federal and state funds and that any falsification or concealment of
material fact may be prosecuted under Federal and State laws.
2. Providers must safeguard the Medicaid program against abuse in the use of electronic claims
submission.
3. Providers must correctly enter the claims data, monitor the data and certify that the data entered is
correct.
4. Providers must assure that the transmission of claims data is restricted to al,lthorized personnel to
prevent erroneous payments by the Agency's fiscal agent that might result from carelessness or fraud.
5. Providers must have on file the applicable source data to substantiate the claim submitted to the
Medicaid program.
6. Providers must allow the Agency or any of its designees and representatives of the office of the
Auditor General or the Attorney General to review and copy all records, including source documents
and data related to information entered through electronic claims submission.
7. Providers must abide by all Federal and State statutes, rules, regulations, and manuals governing the
Florida Medicaid program.
8. Providers must sign and adhere to all conditions of the Medicaid Provider Agreement and be officially
enrolled in the Medicaid program to participate in electronic claims submission.
BY:
(Provider/Representative Signature)
(Date)
Mailing AddressJ?_ 0 B 0')( Od-bO\ \
Provider ID Number: 0811.3" \ - 00
Telephone # used for
Making and Receiving Calls: e,OO -l..\ 11- J... \ 65
_M '~M i \=- L 331oa-
)
Telephone # used for
Claims Submission: Boo - 4- \ 1- d.. \ 6 S
loo\\
(Florida Medicaid Program - Do not write below this line)
Date Received
Received By
FMMIS Update
Title
ECS Spec
Date
Revised March 1999