Item C22
BOARD OF COUNTY COMMISSIONERS ~~
AGENDA ITEM SUMMARY -Louis LaTorre,
Social Services Director
Meeting Date: 07/1 '1-18/02
Division: Community Services
Bulk Item: Yes ~ No
Department: Social Services/Transportation
AGENDA ITEM WORDING: Approval of an agreement between Momoe County and Agency for
Health Care Administration Florida Medicaid.
ITEM BACKGROUND: This agreement will allow Monroe County to receive claim remittance
vouchers electronically for EMS, Transportation, In-Home Services, Bayshore Manor, Assisted Care
Services, and the Nutrition programs.
PREVIOUS REVELANT BOCC ACTION: N/A
CONTRACT/AGREEMENT CHANGES: N/A
STAFF RECOMMENDATIONS: Approval of Agreement
TOTAL COST: N/ A
COST TO COUNTY: N/A
BUDGETED: Yes N/A No
REVENUE PRODUCING: Yes N/A No
AMOUNT PER MONTH N/A
Year
APPROVED BY: County Arty _ OMB/Purchasing _ Risk Management _
DOCUMENTATION:
Included X
To Follow
DMSION DIRECTOR APPROVAL:
Not Required
AGENDA ITEM # ~/~
DISPOSITION:
Revised 2/27/0]
f'rom EDI Suppon Unit fo SalVolone
Dale: 6/12/02 Time: 11: 14:.), i'JVI
. ~~~ .... ...' ....
-
Agency for H:ealth Care:t\dJnJ:~istration
:' " ''':,:~: , ::, ':' \::::::::::,:',:,:,:,:::,:,:,:,.:;."::",,:,::':' ',:'
:Electro n ic i{emlttance:: VQu~ljur24greeD1,e~t
-
Any provider planning to rc(:eive claim remittance vouchers electronically must
complete this form. If you ~ ign this agreement, you will not receive remittance
voucher (RV) banner messages when you receive payment information. '
This AGREEMENT made and entered into this day cf , __, by and
between the Agency for Health C l[,~ Administration, hereinafteJ' called the "Agency," acting in its
own right as the Agency responsihle for administrating the Medical Assistance Program (Title XIX),
and by In-Horne Services , hereinafter called "Prcvider."
WITNESSETH:
In consideratIOn of the mutual pre mlses and covenants containe i herein and other good and valuable
consid~ration, the parties hereto agr.~e as follows:
The Agency shall allow the Provi icr to receive remittance vOU( hers through Internet download from
the fiscal agent's Internet weh site, Please check who will be re( eiving your remittance vouchers.
a.!..- YourselforComplny
b. _ Billing Agent (Ve Idor)
Vmdor's Name)
(Vendor'~ Address)
(Vendo(s Provider Number)
(Ven[j(,(:; Telephone Number)
ProvIder/Representative Signatt rE Char les McCoy
(Notarized siglla/lIre reqllired) Mayor
Date
ProVIder num~r 024921100
ProvIder Address 1100 Simonton st. Rm 1-197
Key Wes~ Fl 33040
(Florida Medicaid Program - Do nol wrltr below this line)
Date Received
Received By
FMMIS Update
Title
ECS Spec
Date
. <JIY~ _ ..." ...J
Ins tru ctio nil n fo rm atio n Sheet
Electronic Reml ttance Voucher Agreeme '1t - Florida Medicaid
ERV Agreements
· Fill out an original copy 01 tre attached ERV Agreement fer each Florida Medica,d Provider
number you are requestirg for Electronic Remittance Vouc;her reports via the Internet.
· Each Agreement must halle a notarized signature before i. can be processed, Leave the
bottom section blank (for ::Iorida Medicaid Program ONL YL If this section is missing, please
contact us at 1-800-829-C218, for a complete copy.
NOTE: If you are currently receiving RV's via "tape'. you will no longer receive
these tapes. The tape a lei ERV (Internet) format ara NOT the same d3tabase
format. Paper remits wil also be discontinued once the Electronic Remittance
Voucher is set up.
Information Sheet
Complete this Informatiol Sheet, and return with thE! original, notarized ERV
Agreement(s) via mail to:
ACS/Consultec
ATTN: Data Exchange
2312 Killeam Center Blvd
Tallahassee, FL 32308
--------------------------------.----------------------------------------------------------------
Contact Information
Contact Name Sal
Contact Tel # 305-
E-Mail szap
Jroviders Office
::; :Vendor/BiJlili{t Agent
:p#tCf:party who wjll~( r~eiving or
downloading your ERV Reports)
Zappulla
295-3649
pulla@monroe-cle k.com
t-rom: t:UI :>uppon Unit I 0: ~alVotone
uate: 0/12/02 Time: l1:14:,)"U\M
"age,) 01 3
..
Ot~.gencr for Health~at~ ~'~)Jj,!p,!,~!r~ti9~
:;Electron icRemittanceV9~~~n~1~g~~m~pt' ,"
!!!
Any provider planning to rel:eive claim remittance vouchers electronically must
complete this form. If you ~ ign this agreement, you will not receive remittance
voucher (RV) banner messag:es when you receive payment information. '
This AGREEMENT made and entered into this day d , __, by and
between the Agency for Health C If.~ Administration, hereinafter called the "Agency," acting in its
own right as the Agency responsible for administrating the Medical Assistance Program (Title XIX),
and by Nlltri t inn , hereinafter called "Prcvider."
WITNESSETH:
In consideration of the mutual pre [Dlses and covenants containe i herein and other good and valuable
consid~ration, the parties hereto agr~e as follows:
The Agency shall allow the Provi:lcr to receive remittance vouchers through Internet download from
the fiscal agent's Internet web site, Please check who will be re( eiving your remittance vouchers.
a. ~ YourselforComp'lny
b. _ Billing Agent (Ve Idor)
Vmdor's Name)
(Vendor'! Address)
(VemJ<'(:; Telephone Nwnber)
(Vendor's Provider Nwnber)
PrOVIder/Representative Signall r( Charles McCoy
(Notarized siglla/llre reqllired) Mayor
ProVider number 0249211 01
ProVIder Address 1100 Simonton st. Rm 1-201
Key West, FL 33040
Date
(Florida Medicaid Program - Do nol wrllt below this line)
Date Received
Received By
Title
FMMIS Update
ECS Spec
Date
Instructionllnformation Sheet
Electronic Rem. ttance Voucher Agreeme '1t - Florida Medicaid
ERV Agreements
Fill out an original copy of tt- e attached ERV Agreement fer each Florida Medica,d Provider
number you are requestirg for Electronic Remittance Vou(:her reports via the Internet.
. Each Agreement must ha"e a notarized signature before i can be processed_ Leave the
bottom section blank (for =Iorida Medicaid Program ONLY), If this section is missing, please
contact us at 1-800-829-C218, for a complete copy.
NOTE: If you are currently receiving RV's via "tape', you will no longer receive
these tapes, The tape a lei ERV (Internet) format ara NOT the same database
format Paper remits wil also be discontinued once the Electronic Remittance
Voucher is set up.
Information Sheet
Complete this Informatiol Sheet, and return with thf~ original, notarized ERV
Agreement(s) via mail to:
ACS/Consultec
A TTN: Data Exchange
2312 Killeam Center Blvd
Tallahassee, FL 32308
Contact Information
Contact Name Sal
Contact Tel # 305-
E-Mail szap
2
......... .::",,: '" :' :: Vendor/Billing Agent
ovider's Office " :Pl:herparty who will ~( r~eiving or
" doWnloading your ERV Reports)
appulla
95-3649
ulla@monroe-cle k.com
Jr
z
p
"VIII L.UI vUPJJUli UllIl IV. ~aIV\.IlU'It:
Udle: OIl.!JUL limE I I I 't..>~ f'\JVI
/""'age..l or.J
A.gency for Health Care~'4]ni~istrati~n
:Electron icRemittance"Vouc~c~r:~greement
!!!!
-
Any provider planning to rc(:eive claim remittance vouchers electronically must
complete this form. If you ~ ign this agreement, you will not receive remittance
voucher (RV) banner messag;es when you receive payment information. .
This AGREEMENT made and entered into this day co[ I __, by and
between the Agency for Health C U"t~ Administration, hereinafte:' called the "Agency." acting in its
own right as the Agency responsibk for administrating the Medical Assistance Program (Title XIX),
and by Assis..ted Care _, hereinafter called "Prcvider."
Services
WITNESSETH:
In consideration of the mutual pre mlses and covenants cont.aine i herein and other good and valuable
consid~ration, the parties hereto agr~e as follows:
The Agency shall allow the Provi:icr to receive remittance voue hers through Internet download from
the fiscal agent's Internet web site. Please check who will be ree eiving your remittance vouchers.
a..L YOllrselforComplny
b. _ Billing Agent (Ve Idor)
V.mdor's Name)
(Vendor'~ Address)
(Vendl-r',: Telephone Nwnber)
(Vendor's Provider Nwnber)
Date
ProvIder/Representative Signatl rE Charles McCoy
(Notarized siglla/lIre reqllired) Mayor
ProvIder num~r
140159900
5200 College Rd.
ProvIder Address
Key West, PI 33040
(Florida Medicaid Program - Do not writr below this line)
Date Received
Received By
Title
FMMIS Update
ECS Spec
Date
. u~... _ '-', ..J
Instructionllnformation Sheet
Electronic Rem/ ttance Voucher Agreeme,.,t - Florida Medicaid
ERV Agreements
. Fill out an original copy of It. e attached ERV Agreement fer each Florida Medica,d Provider
number you are requestirg for Electronic Remittance Vouc:her reports via the Internet.
. Each Agreement must ha ~e a notarized signature before i, can be processed. Leave the
bottom section blank (for :Iorida Medicaid Program ONLY l. If this section is missing. please
contact us at 1-800-829-C218. for a complete copy.
NOTE: If you are currently receiving RV's via "tape', you will no longer receive
these tapes. The tape a lei ERV (Internet) format ar3 NOT the same d3tabase
format. Paper remits wil also be discontinued once the Electronic Remittance
Voucher is set up.
Information Sheet
Complete this Informatiol Sheet. and return with thf! original, notarizecl ERV
Agreement(s) via mail to:
ACS/Consultec
A TTN: Data Exchange
2312 Killeam Center Blvd
Tallahassee. Fl32308
Contact Information
Contact Name Sal
Contact Tel # 305-
E-Mail szap
Jrovider's Office
....,:, :Vendor/Billirig: Agent
~9~er:p~rty who willR( r~ving or
oownloading yourERV Reports)
Zappulla
295-3649
pulla@monroe-cle k.com
-'-0. __. _....,............ .......... ......_ ................"'..0;;;
Vdlt:. O/I"'U~ limE: 11: loIt."'~ '""VI
I-'age J of 3
Iii
A.gency for I1~alth qareAlndl1i~ttatio~ .
, :". ' .....:,.~, ': .::, > '.".:::::::::':::.;,::..:...:::::..::.:.'::,..::::,..:/':: ,,"
Electron iCR.elD~tt~~ceVQu~~nr~g~~IIl~!tt;
!!!!
Any provider planning to rc(:eive claim remittance vouchers electronically must
complete this form. If you ~ ign this agreement, you will not receive remittance
voucher (RV) banner messag;es when you receive payment information. .
This AGREEMENT made and entered into this day co[ , __, by and
between the Agency for Health C lr.~ Administration, hereinafteJ' called the "Agency," acting in its
own right as the Agency responsibk for administrating the Medical Assistance Program (Title XIX),
and by Bayshore Manor _, hereinafter called "Prcvider."
WITNESSETH:
In consideration of the mutual pre mlses and covenants cont.aine i herein and other good and valuable
consid~ration, the parties hereto agr~e as follows:
The Agency shall allow the Provdcr to receive remittance vouchers through Internet download from
the fiscal agent's Internet web site. Please check who will be receiving your remittance vouchers.
a..L YOllrselforComplny
b. _ Billing Agent (Ve Idor)
(Vendor'~ Address)
V.;ndor's Name)
(Vendl'I':: Telephone Nwnber)
(Vendor's Provider Nwnber)
ProvIder/Representative Signatl rE Char les McCoy
(Notarized signa/lire required) Mayor
Date
Provider num~r 676448700
ProvIder Address 5200 College Rd.
Key West, PL 33040
(Florida Medicaid Program - Do not wrltr below this line)
Date Received
Received By
Title
FMMIS Update
ECS Spec
Date
..
Instructionllnformation Sheet
Electronic RemJ ttance Voucher Agreeme Ilt - Florida M,edicaid
ERV Agreements
Fill out an original copy of tl- e attached ERV Agreement fer each Florida Medica.d Provider
number you are requestirg for Electronic Remittance Vouc:her reports via the Internet.
· Each Agreement must hal/e a notarized signature before i: can be processed. Leave the
bottom section blank (for =Iorida Medicaid Program ONLY). If this section is missing. please
contact us at 1-800-829-C218, for a complete copy.
NOTE: If you are currently receiving RV's via -tape', you will no longer receive
these tapes. The tape a lei ERV (Internet) format are NOT the same d3tabase
format. Paper remits wil also be discontinued once the Electronic Remittance
Voucher is set up.
Information Sheet
Complete this Informatio 1 Sheet. and return with thE! original. notarized ERV
Agreement(s) via mail to:
ACS/Consultec
A TTN: Data Exchange
2312 Killeam Center Blvd
Tallahassee, FL 32308
Contact Information
Contact Name Sal
Contact Tel # 305-
E.Mail sza
'::::: Vendor/BiJling: Agent
~g#Ierparty who Wm~t r~ving or
"oownl~aaing yourERV Reports)
Zappulla
295-3649
ppulla@monroe-cle k.com
. ._.... _..... ....U'"'~Vl~ '-"'''~ '..... .....Uly...'~U"1I;;;
..."a~1l;;. U'ILJU~ 111I1t:. 11.......--.-..
, ....~'-... VI ..J
-
Agenc)' for T-J:~.althGar~~:4]~~,9I~~r21ti~p
Eh~ctron icRemittanc~ Y:911~~c~r;~~em~pt,
!!!! '
Any provider planning to rc(:eive claim remittance vouchers electronically must
complete this form. If you ~ i~:n this agreement, you will not receive remittance
voucher (RV) banner messag;es when you receive payment information. '
This AGREEMENT made and entered into this day <of , __, by and
between the Agency for Health C lr,~ Administration, hereinafteJ' called the "Agency," acting in its
own right as the Agency responsihk for administrating the Medical Assistance Program (Tille XIX),
and by Transportation _, hereinafter called "Prcvider."
WITNESSETH:
In consideration of the mutual pre mlses and covenants cont.aine i herein and other good and valuable
consid~ration, the parties hereto agr~e as follows:
The Agency shall allow the Provi:lcr to receive remittance voue hers through Internet download from
the fiscal agent's Internet weh site, Please check who will he re( eiving your remittance vouchers.
a..L YOllrselforComplny
b. _ Billing Agent (Ve Idor)
VmdoI's Name)
(Vendor'! Address)
(Vendl'I':; Telephone Nwnber)
(Vendor's Provider Nwnber)
PrOVIder/Representative Signall n: Charles McCoy
(Notarized siglla/lIre required) Mayor
Date
Provider Ilum~r 0881 511 00
ProvIder Address 1100 Simonton st. Rm 1-181
Key West, PL 33040
(Florida Medicaid Program - Do not wrltr below this line)
Date Received
Received By
Title
FMMIS Update
ECS Spec
Date
Instructionllnformation Sheet
Electronic RemJ ttance Voucher Agreeme,.,t - Florida Medicaid
ERV Agreements
. Fill out an original copy of U. e attached ERV Agreement fer each Florida Medica.d Provider
number you are requestirg for Electronic Remittance Vouc;her reports via the Internet.
. Each Agreement must ha~e a notarized signature before i. can be processed. Leave the
bottom section blank (for ::Iorida Medicaid Program ONL Yl. If this section is missing, please
contact us at 1-800-829-C218, for a complete copy,
NOTE: If you are currently receiving RV's via "tape'. you will no longer receive
these tapes, The tape a lei ERV (Internet) format are NOT the same d3tabase
format. Paper remits wil also be discontinued once the Electronic Remittance
Voucher is set up.
Information Sheet
Complete this Informatiol Sheet, and return with thf~ original. notarizecl ERV
A.greement(s) via mail to:
ACS/Consultec
ATTN: Data Exchange
2312 Killeam Center Blvd
Tallahassee. FL 32308
Contact Information
Contact Name Sal
Contact Tel # 305-
E-Mail szap
::: Vendor/BiJlilig Agent
:9ttrefparty who will~( r~eivinR or
dOwnloading your ERV Reports)
Zappulla
295-3649
pulla@monroe-cle k.com
-
~gency for ffealth Care14n~j~,~,strati()11
,Electronic Remittance V()u~~ur;~~~el1l.eijt
!!!!
Any provider planning to rc(:eive claim remittance vouchers electronically must
complete this form. If you ~ i~~n this agreement, you will not receive remittance
voucher (RV) banner messages when you receive payment information. .
This AGREEMENT made and entered into this day co[ , __, by and
between the Agency for Health C :W~ Administration, hereinafteJ" called the "Agency," acting in its
own right as the Agency responsihlt: for administrating the Medical Assistance Program (Title XIX),
and by EM~ __, hereinafter called "Prcvider."
WITNESSETH:
In consideration of the mutual pre mlses and covenants cont.aine i herein and other good and valuable
consid~ration, the parties hereto agr~e as follows:
The Agcncy shall allow the Provi icr to reccive remittance voue hers through Internet download from
the fiscal agent's Internet web site, Please check who will be rec eiving your remittance vouchers.
a..L YOllrselforComplny
b. _ Billing Agent (Ve Idor)
(Vendor'~ Address)
V;ndor's Name)
(Vendor's Provider Nwnber)
(Vendl'r';; Telephone Nwnber)
ProVider/Representative Signall n:: Charles McCoy
(Notarized siglla/llre reqllired) Mayor
Date
ProVider num~r 087736100
ProVider Address 4 q n h 1 rn S t S h'! 1 70
Marathon, PL 33050
(Florida Medicaid Program - Do not wrltr below this line)
Date Received
Received By
FMMIS Update
Title
ECS Spec
Date
- .
Instructionllnformation Sheet
Electronic Reml ttance Voucher Agreeme 'lt - Florida Medicaid
ERV Agreements
"
. Fill out an original copy of tte attached ERV Agreement fer each Florida Medica,d Provider
number you are requestirg for Electronic Remittance Vouc:her reports via the Internet.
· Each Agreement must hav'e a notarized signature before i: can be processed. Leave the
bottom section blank (for :Iorida Medicaid Program ONLY), If this section is missing. please
contact us at 1-800-829-C218, for a complete copy.
NOTE: If you are currently receiving RV's via "tape', you will no longer receive
these tapes. The tape a lei ERV (Internet) format are NOT the same database
format. Paper remits wil also be discontinued once the Electronic Remittance
Voucher is set up.
Information Sheet
Complete this Informatiol Sheet, and return with thE! original. notarizecl ERV
Agreement(s) via mail to:
ACS/Consultec
A TIN: Data Exchange
2312 Killeam Center Blvd
Tallahassee. FL 32308
-.------------------------------.----------------------------------------------------------------
Contact Information
... .,
.
Contact Name Sal
Contact Tel # 305-
E-Mail szap
":::::::':Vendor/BiJling: Agent
~~:p:~r whQ\ViU~(r~ving or
, "dOWDloading yourBR:V Reports)
Zappulla
295-3649
pulla@monroe-cle k.com