Item F24
BOARD OF COUNTY COMMISSIONERS
<<-tr~
Louis LaTorre
AGENDA ITEM SUMMARY
Meeting Date: 111~7_1-22 / 00
Division: Community Services
Bulk Item: Yes L- No
Department: Social Services Transportation
AGENDA ITEM WORDING:
Approval of continuation between State of Florida Agency for Health Care Administration and Monroe County
Board of County Commissionersrrransportation Program,
ITEM BACKGROUND:
This is the continuation of a contract for the purpose of billing Medicaid.
PREVIOUS RELEVANT BOCC ACTION:
July 21, 1999
STAFF RECOMMENDATION:
Approval
TOTAL COST:
o
BUDGETED: Yes NA
No
COST TO COUNTY: 0
DIVISION DIRECTOR APPROVAL:
YEAR $30.000.00
REVENUE PRODUCING: YES X NO
APPROVED BY: County Atty. X 0
C>
DOCUMENTATION:
To Follow:
Not Required: _
Agendaltem#: ~
DISPOSITION:
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract #
Contract with: State of Florida Agencv for Health Care Administration Effective Date: -Ll/.2.LI 00
Expiration Date: Unknown
Contract PurposelDescription: Medicaid Provider Agreement for Medicaid recipients for fee,
Contract Manager:
J
Eskew
(Name)
Social Services
(Department)
furBOCCm~ti~on-UJ~/~
Agenda Deadline: lLJ 7. - - I-.Jill..
CONTRACT COSTS
Total Dollar Value of Contract: $ -0- Current Year Portion: $ -0-
Budgeted ? Yes No ...x..- Account Codes: - - - -
- -
Grant: $ N/A - - - -
-
County Match: N/A - - - -
-
ADDITIONAL COSTS
Estimated O~oing Costs: $ 0 Iyr. For:
(Not included in dollar value above) (e.g. maintenance, utilities, janitorial, salaries, etc.)
CONTRACT REVIEW
Changes
Date In Needed Date Out
Yes N:r--
Division Director IQ."/2'3 1 00 () t '0 17.3/00
---
Risk M"""E; ~~.l) 1 DO ( ) lJUzSf {Ie
~.lPu ~ J.QP,5/ (tJ ( ) /0 1 xcro
---
County Attorney 10 IJ[, /Q:!2 ( ) Jpj )..{I crz;
Comments:
Florida Medicaid Re-enrollment
Facility Profile Verification
This is the information as it appears in your Provider File as of 06/22/2000, Please
review and update if necessary using the space provided.
Provider Number and Type 088151100
PUBLIC TRANSPORTATION
Provider Name
MONROECOBRDOFCOCOMM
Doing Busi'ness As Name
H: ::O~e :6r: mare :01: :m~:::: :::: ::::::
P:: :a:ddiesses: :h~v:e: :chati':'~d;
..................... .........Q....
:::::::.: Pi:ease :5etld::a :serial:it:ed:::
::::::::: :~~~rige: of: A.dd:r~ss: 16mi:::
::::::::}~:m~:~~dr.~SS:~~18~::::::::::.
. . . . . . . . . . . . . . . . . , . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . .
. .................... ........ -..
..... ... ...
Business Address
(P,Q. Boxes not accepted)
TRANSPORTATION PROGRAM
5100 COLLEGE RD
KEY WEST, FL 33040
Payment Address
TRANSPORTATION PROGRAM
5100 COLLEGE RD
KEY WEST, FL 33040
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........ .
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... ........
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............ ........... ......
.......-....... .......... .......
Correspondence Address
TRANSPORTATION PROGRAM
5100 COLLEGE RD
KEY WEST, FL 33040
........ ......
........... ......
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........ ..
.... -. .....
... ,.. ....
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.. ... .............
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.. ..-........ ....... ....... .....
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County of Operation
Telephone Number
Tax 10 Number
Payment Method
MONROE
396 2Q~ 8408 .
305 2H2. 44ZZ.
59-6000749
E=ELECTRONIC TRANSFER
(Attach a copy of 88-4)
............ .
. ... .................... ..... ......
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
W: M~Majt:: :YOq: ::mq~:: ~ijcfu~e:
:3:com 'letixLE.F.:1>a: re.emenk
-:.:-:-:.:.:.:.p.:.:.:.:.....:.:.:.:.:.:.:.g.:-:...:-:-:.:-:-:-:-:
Background Screening
It is the responsibility of the provider to know the provisions of Section 409.907, Florida
Statutes, and to be certain that the names and appropiiate identifying infoimation fOi aii
provider personnel on whom criminal history checks are required are submitted with this Profile
Verification. Please list below all partners or shareholders with ownership interest of five
percent or more and all officers, directors, billing agents, and managers of this business. Use
an additional sheet if necessary.
Print Each Name SSN License # % Own
G 2. cO ~ '?> 2 4'" 02..7 0
.J~ '( E'"~t<.e L.U 3'7 A.# f... 51 'I 5 t L 0
nm
\
Previous Background
Screening Completed?
~ No
Yes No
Yes No
StP VI 2000
AUG 4 2000
Yes
No
t RECEIVED
004326
Verification:
DYes 0 No Have all partners or shareholders with ownership interest of five percent or more
and all officers, directors, billing agents, and managers submitted fingerprints
within the last 12 months for background screening as outlined in Section
409.907, Florida Statutes? If not then submit a completed fingerprint card
with a check for $39 made payable to Consultec for each person. Include
these cards and checks with your Profile Verification.
DYes 0 No Do you provide services using a fully operational physician vehicle, unit, trailer
or office that travels to different locations for the provision of physician services
and is not a stationary physician unit or office? If yes, please attach a copy of
your contract with a county health department, federally qualified health
center, or rural health clinic and return with your Profile Verification.
DYes 0 No Have you attached proof of current bond coverage? This applies only to DME
and Home Health Agency providers.
DYes 0 No Has this facility had a change in ownership? If yes, give the date of change in
ownership.
o Check here if ... all partners or shareholders with ownership interest of five percent or more and
all officers, directors, billing agents, and managers have signed the enclosed
Medicaid Provider Agreement. Please submit the original signed document
with your Profile Verification.
I have reviewed this information and have made any necessary updates. I understand that it is
my responsibility to notify Medicaid's fiscal agent of any change to the information in my
provider file, including but not limited to, a change of address, group affiliation, ownership,
officers, directors, or tax identification number. All attachments required to update my file are
included with this re-enrollment packet.
I further understand that under Section 409.920(2)(f), Florida Statutes, the filing of materially
incomplete or false information with this re-enrollment verification is a third degree felony and
is sufficient cause for termination from the Florida Medicaid Program.
~u D01.7 /Jf/U77
~l.{^a.,n eo A .l:LJ+-on -'J5-~/Jh~J1f Cvwlf, !lfl-()rf'l~
Printed name of signatory above Title
The Final Step:
Mail your re-enrollment packet and any required attachments to the address below. If you have
any questions, please call the Consultec Enrollment Unit at 800-377-8216.
CONSUL TEC
Provider Enrollment
P.O. Box 13800
Tallahassee, FL 32317-3800
004327
. 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 AHCA OF THE
SUBMISSION OF A MATERIALLY INCOMPLETE. MISLEADING OR FALSE PROVIDER APPLICATION UNLESS
SUBSEQUENTLY RATIFIED OR-APPROVED BY AHCA.
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 AHCA.
FOR OFFICE USE ONLY
The provider's name is: _______________________ .
The facility's name is:
The provider number is:
IN WITNESS WJ-\EREOF. the undersigned have caused this agreement to be duly executed under the penalties of
perj\lry. swearhQr affirm that the foregoing is true and correct.
Signature of Provider
Date
Signature of Provider
Date
(legibly print the above signature) Title
(legibly print the above signature) Title
.
Signature of Provider
Date
Signature of Provider Date
(legibly print the above signature) Title
(legibly print the above signature) Title
Signature of Provider
Date
Signature of Provider
Date
(legibly print the above signature) Title
(legibly print the above signature) Title
Signature of Provider
Date
Signature of Provider
Date
(legibly print the above signature) Title
(legibly print the above signature) Title
Signature of Provider
Date
Signature of Provider
Date
(USE ADDITIONAL PAGES IF NECESSARY)
MPA RevIsed July 19'}'l
3
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MONROE COUNTY BOARD OF COUNTY COMMISSIONERS is submitting the
(priDr IIIDIe of IQIDiuliClllIIr iIldiYidull provider)
attached application to become a Medicaid provider.
...;.
This organization is requesting exemption from the fingerprinting and criminal history check
requirements under Chapter 409, Florida Statutes, on the following basis:
(Check aU lhat apply)
..:
C This organization is a School District, and is exempt under Section 409,908, F10rida
Statutes.
C This organization is a hospital licensed, under Chapter 395. Florida Statutes.
tJ This organization is a nW'Sing home licensed under Chapter 400, Florida Statutes.
CJ This organization is a hospice licensed under Chapter 400, Florida Statutes.
l:J This organization is an assisted living facility licensed under Chapter 400, Florida Statutes.
CI This organization is a unit of local government (see note below).
C This organization derives more than 50% of its revenue from the sale of goods to final
consumers AND
C 1. is reqUired to file a form 10K with the securities and Exchange Commission OR
CJ 2, Has a net worth of $50 million or more.
"
...
Documentation (llIlDuaI report iDcluding audited financial statements and/or lOK form)
must be submitted with any exemption request under this category.
-~'."'."": .-_. ...".-,... .,..,-'.-..-.
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Underpenaltyofpeljury, I do hereby certify that MONROE COUNTY BOARD OF COUNTY COMMISSIC
(Name of Organization or Indi vidual Provider)
meets one or more of the criteria specified above,
J_?~
Signature of CEO of Organization or
SUperintendent of School District
,/b-{/do
Date /
...
JmE&' L .f?n/Y2!-iS
Print name of above signatory party
ARCA Form 2200.0003 (July 1999)
APPLICATION Page 25
G0~
IG1'ON
Ilt't'G6G~0n6 ~ l.tB.fT10dN3 (lOdd
~G:60
000G/'6G/'80
C N5ULTEC
INC-
. P,ROVIDER RE-ENROLLMENT UNIT
PO Box 13800
Tallahassee, FL 32317-3800
MONROE CO. BRD. OF CO. COMM.
TRANSPORTATION PROGRAM
5100 COLLEGE ROAD
KEY WEST, FL 33040
"-.J~
J'
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G
Your Re-enrollment Facility Profile Verification must be returned for the reasons indicated below,
Please make the corrections, attach all required documentation and resubmit entire packet to the address
above,
D Provide proof of change to Tax ID number.
D Submit a completed Authorization Agreement for Electronic Funds Transfer (EFT).
D A void check, deposit slip, or bank letter verifying the ABA and Account Numbers is necessary to
complete your Electronic Funds Transfer document.
. The information listing all partners or shareholders with ownership interest of five percent or more
and all officers, directors, billing agents and tl1ana~ers of this busmess is insufficient.
THE ACHA FORM STATES THAT YOU ARE A UNIT OF LOCAL GOVERNMENT AND
THEREFORE EXEMPT FROM A BACKGROUND CHECK. HOWEVER, THIS SECTION
STILL NEEDS TO BE COMPLETED. PLEASE LIST YOUR DIRECTORS AND/OR
MANAGERS IN THIS SECTION AND HA VE THEM ALL SIGN THE MEDICAID
AGREEMENT, THE PERSON WHO SIGNS THIS APPLICATION MUST ALSO BE LISTED
HERE,
PLEASE ANSWER THE QUESTIONS ON PAGE 2 OF THE APPLICATION.
D Indicate whether or not you are providing services as a mobile unit. If yes, attach a copy of your
contract.
D A copy of current Surety Bond coverage must be provided, including the Power of Attorney.
D Change of Ownership inquiry must have a response.
. All partners or shareholders with ownership interest of five percent or more and all officers,
directors, billing agents and managers of tliis business must sign the Medicaid Provider Agreement.
D The authorized agent must sign the Profile Verification, Please print the name of signatory, date and
title,
D Original signatures are required on all documents,
Please contact the Enrollment Unit at 800-377-8216 for further assistance.
Date
1(00 ILl)
/ /
NON-INSTITUTIONAL
MEDICAID PROVIDER AGREEMENT
-Jt:AiiCA
AGENCY FOR HEALTH CARE AWINISTRATION
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) Qualitv 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 services or goods must have been actually
provided to eligible Medicaid recipients by the provider prior to submitting the claim.
(3) Comoliance. The provider agrees that the submission for payment of claims for services will constitute a certification
that the services were provided in accordance with local, state and federal laws, as well as rules and regulations 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 have
been met, this agreement shall remain in effect for five (5) years from the effective date of the provider's eligibility unless
otherwise terminated. This agreement shall be renewable only by mutual consent. The provider understands and agrees
that no AHCA signature is required to make this agreement valid and enforcable.
(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 being 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, 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 can not be separated 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) Within 90 days of receipt, refund any moneys received in error or in excess of the amount to which the provider is
entitled from the Medicaid program.
(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.
MPA Revised July 19<)1)