Item C08
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: 08/18-19/04
Division:
Community Services
Bulk Item: Yes --X- No
~~: SOC~S~T~
Social ServIces Drrector: ~~
Louis LaTorre
AGENDA ITEM WORDING: Approval of a contract between Monroe County and WebMD
ITEM BACKGROUND: This agreement will allow Monroe County Transportation personnel to check
on Medicaid status as weD as Medicaid numbers. As we do the billing for Medicaid eligible Medicaid
Transportation trips. We have been using this software for the past 7 years to obtain this information and
in the past a contract/fee was not required.
PREVIOUS RELEVANT BOCC ACTION: N/A
CONTRACT/AGREEMENT CHANGES: N/A
STAFF RECOMMENDATIONS: Approval
TOTAL COST:$49.90 ($24.95 1st month and $24.95 set up fee) and $24.95 monthly thereafter
BUDGETED: Yes --X- No
COST TO COUNTY: $49. 90 ($24.95 1st month and $24.95 set up fee) and $24.95 monthly thereafter
SOURCE OF FUNDS:I02-6150S
REVENUE PRODUCING: Yes X No AMO
.J11~"\
APPROVED BY: County Al~\- OMB/Purchas
DMSION DIRECTOR APPROVAL:
PER MONTH_ Year
DOCUMENTATION:
Included X
To Follow
Not Required
AGENDA ITEM # Q~
DISPosmON:
Revised 1/03
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: WebMD Contract # -
Effective Date: April 21, 2004
Expiration Date: No Expiration Date
Contract Purpose/Description:
This agreement. will allow Monroe County Transportation personnel to check on Medicaid
status as well as Medicaid numbers. As we do the billin~ for Medicaid eli~ible Medicaid
Trans.portation trips. We have been using this software for the past 7 years to obtain this
information and in the nast a contract/fee was not reouired.
Contract Manager: Jerry Eskew 4425 Transportation/l
(Name) (Ext.) (Department/Stop #)
for BOCC meetinj!; on 08/18-19/04 Aj!;enda Deadline: 08/03/04
CONTRACT COSTS
Total Dollar Value of Contract: $ 0
Budgeted? Y es~ No D Account Codes:
Grant: $
County Match: $
Current Year Portion: $ 74.85
102-61505-530-520-_
- - - -
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- - - -
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- - - -
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ADDITIONAL COSTS
Estimated Ongoing Costs: $299.40/yr For: monthly payments of$24.95
ot included in dollar value above . maintenance, utilities, .anitorial, salaries, etc.
CONTRACT REVIEW
'1,/~l~n
Division Director L I
Risk Management )s ~~
Date Out
O.M.B./Purchasing YesD No
County Attorney q#W
Comments:
From:WEBMD:MEMPHIS
8436688
07/20/2004 15:40 #578 P .002/012
WebMD
30S5 LebllDon Road Bldg.3 Suite 2000
Nashville, tN 37214
If you have questions on how to complete this form
or on the status of your enrollment. olease call
the enrollment help desk at 1-800.845-6592.
Florida Medicaid Enrollment for Real.. Time Transactions
For WebMD Office
I Please complete all information. Mail this form to the address listed above.
-
Provider/Group Name; GO U (\ I rQ () S U(
Provider Address: IIOD S llY)nn-\-or\ .:-:IT. ~rYl l- \g I
Provider City. State, Zip: 0
OVl
Contact N me:
Provider Phone Number:
.BD:c5 ..a~ ~-Ll '-\"d. ~
Fax Number-for ap!roval notice: 30"5 - a ~a - 4 Ll , J
Tax 10: 5~DI3~~eaOSD55~t~ FE.r/Ln set -loccCr7Y<i
Provider Number (must be nine digits): 0 cg ~ 15 11 - DO
. Practice address must reflect the physical location where eligibility will be verified.
. If Practice has multiple locatioos where eligibility will be verified, each location and corresponding
provider number must be submitted for enroJJment. Please copy form as needed.
· Provider nwnber must be associated with the Practice/Physician name and location,
· Billing Agencies must have a specific provider number assigned by the AReA (beginning with 99)
along with submission of "inient and disclosure" and subsequent approval from AHeA for requesting
eligibility data.
.
F{}T Internal Use Only:
Please indk.ate an applic..'tble HIP user names (please write clearly):
--
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From:WEBMD:MEMPHIS
8436688
07120/2004 15:41 #578 P.OOO/012
WebMD Office Provider Subscriber Agreement Customer t:
FIe t#:
Siebel Opportunity Number: Contract ID:
This is a binding agreement I"Agreement") beCween EMlOY Corporation d/b/a WebMD ENVOY ('Wo", .Us" or "Oul") and the organization named on this fonn
("You" or "YOu"'). This Agreement govems VOIJll use of the WebMD OffIce Web Site. including, without Umllation. all content such as text. infonnation. images,
and audio (ccllectively. "0 "Can..n..) and all services ("Services") made available to You through the WebMD OffICe Web Sile by Us and/or third parties
(lnclidlng. without limitation, WebMD 0lIce SeIvic:eS). ThIa Agreement Inetudes the Generat Terms 8nd the Spec181 Terms for WebMD otIice Services set forth
on the reveille sido of thIs document. 'Site" 8S used in this Agreement means the WebMD Office Web Site. the Content. and the Servi:es.
Select On" of the Following: Complem Sections:
-tzl,.New Pl'OIicler Customer Organization and New Users ' ", ",. IV. V. VI & V1I, Users Entol1m&nt Form & Payer Forms
o Ctlanging PricIng Plan for Existing WebMD Office Provider Customer Organizations and or VIII. V & VI
Users
o Adding New Users \0 existing WebMD OffIce Provider Customer Organizations None; WebMD OffICe Users Enrollment Form
o AddIng Real-Time Payers to existing WebMD Office Provider Customer Organizations and None; Additional Real- Trme Payer Enrol/mer4 Forms
U5ef$
o Adding WebMD Office 10 Existing WebMD Practice Provider Customer Organizations and . II, III, IV, V. VI ,$ VII. UselS Enrol/menl Form & Payer Forms
Users
Section 11- Line of Business
~In. of Business: 0 MedicaiD Hospital J
Sect/on IV - Real- nme Carriers
Please see Schedule IV attached for Real-Time Carriers that may require additional paperwork.
S tfo
SecUon 111- Practice Management or Hosplt1lllnformat/on System
~ystem Name:
ec n V - Prlcina - Please select II Package below
Non-Partlclpating Partlclpefing
PJfclnll Pacbge Payer Payer Fees Owed
Monthly Transactions Transaclons One Time
Subscrlptlon WebMD
Selection Fee Each AdI1I/iotIaI Ollce 1" Month Monthly (AflN
Name Included '"eIuded
Tr.JlWlcUon Setup Fee (Mon;::t' .. 1" Month))
(Per~J
0 Real-Time Basic $9.95 None $0.45 Unlimited 524.95 $34.90 $9.95
~ Real-Time 100 $24.95 100 $0.25 Unlimited $24.95 $49.90 524.95
TOTAL SETUP FEES s4.q.QD
Sect/on VI - Acknow/edaements
~USTOMERORGAN~TlON IENVOY CORPORA TION dlbh~ WebMD ENVOV I
hav.the aulhority to. and hereby do, enler into this Agreement on bel1a1f of my Orgarizalion,
neluding on behalf of all physlc:lans. other providers and users affiliated with this Organization. I
[understand that my Organization is legally bound by the lerms and conditions of this Agreement.
~y (Au/hOf;ad Signalur&} Date ay (Aurl>OriZed SIgn-J
ame & TIlle Inrinl or Iv~) ~ame & Tile (prinl or type)
Sect/on VII - Sales and Marketln Informatfon
nitiatlve: 0 No ; 0 Yes If Yes. what Initiative?:
Sales Division Inside Sales
ales Person: Sylvia A. Poll
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8436688
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SCHEDULE IV
REAL-TIME CARRIERS
Please select the Real-Time Carriers to which you would like to submit transactions:
Addition.' Enrollment Form Reaulred
o BLUE CROSS BLUE SHIELD OF GEORGIA
o NEW YORK MEDICAID
o UNITED HEAL THCARE REFERRALS I CLAIM STATUS
o BLUE CROSS OF CALIFORNIA
o BLUE CROSS BLUE SHIELD OF ILLINOIS
o BLUE CROSS BLUE SHIELD OF MINNESOTA
a FLORIDA MEDICAID
Additional Enrollment Form Reaulred with ORIGINAL Signature
o BLUE CROSS BLUE SHIELD OF FLORIDA
o BLUE CROSS BLUE SHIELD OF TEXAS (Must be accompanied by form "Sample Leiter" on Physiclan Letterhead)
o BLUE CROSS BLUE SHIELD OF NEW MEXICO (M.lst be accompanied by fonn -Sample Letter" on Physician Letterhead)
o BLUE CROSS BLUE SHIELD OF ALABAMA
WebMD Office Real-Time Carrier Enrollment Form 01/04
5
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