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10/18/2000 Agreement Clelll Of De CirCuI Coon Danny L. Kolhage Phone: 305-292-8550 Fax: 305-296-3616 Memnrandum To: Reggie Paros, Director Public Safety Department From: Isabel C. DeSant~, 1'1 C A- Deputy Clerk '-Y.. /../. Date: Tuesday, November 7, 2000 At the Board of Commissioners' Meeting on October 18, 2000, the Board granted approval and authorized execution of the fOllowing: 1. Medicare EDI Enrollment Form in regards to ambulance billing services. 2. Non-Institutional Medicaid Provider Agreement in regards to ambulance billing services. 3. Florida Medicaid Provider/Billing Agent Agreement in regards to ambulance billing services. 4. Agency for Health Care Administration Electronic Claims Submission Agreement in regards to ambulance billing services. 5. Agreement between Monroe County and the City of Key West concerning the issuance and utilization of automated external defibrillators Attached are fully-executed duplicate originals of the above documents for your handling. Should you have any questions concerning this matter please feel free to contact this office. Copies: Finance County Attorney File ~. b~ ~~ r\~:t.~ "a:""~ /! ~.. ~~ ~ ... ~.. ... ,.- ,;::...~~~- '- r.....~ JIl:" -,\J ~ ..._.M~ . ~T\~ NON-INSTITUTIONAL MEDICAID PROVIDER AGREEMENT ~it:AHCA AGENCY fOR HfAlTH CARE ADWIN 1ST RATIO N 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) Quality 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 cQDsti~e aG2rtif~tion that the services were provided in accordance with local, state and federal laws, as well as rules a(i re~latijs applicable to the Medicaid program, including the Medicaid Provider Handbooks issued by AHCA. :::Oon~ c ~ r .~. -= '--' rrl=,,-< (4 ) Term and sianatures. The parties agree that this is a voluntary agreement between AHCA an~ fifovi~, i~hich the provider agrees to furnish services or goods to Medicaid recipients. Provided that all reqUire~fM en~IIm~ have been met, this agreement shall remain in effect for five (5) years from the effective date of the pro . ~li9ii:iity 'iQtess otherwise terminated. This agreement shall be renewable only by mutual consent. The provider urmerS~dU1d ~ees that no AHCA signature is required to make this agreement valid and enforcable. ;.' c ~. 0 I ~", :::0 . .... C) (5) Provider Responsibilities. 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 1999 (h) Accept Medicaid payment as payment in full, and not bill or collect from the recipient or the recipient's responsible party any additional amount except, and only to the extent AHCA permits or requires, co-payments, coinsurance, or deductibles to be paid by the recipient for the services or goods provided. This includes situations in which the provider's Medicare coinsurance claims are denied in accordance with Medicaid's payment. (i) Agrees to submit claims to AHCA electronically and to abide by the terms of the Electronic Claims Submission Agreement. (j) Agrees to receive payment from AHCA by Electronic Funds Transfer (EFT). In the event that AHCA erroneously deposits funds to the provider's account, then the provider agrees that AHCA may withdraw the funds from the account. (6) AHCA Responsibilities. AHCA: (a) Is required to make timely payment at the established rate for services or goods furnished to a recipient by the provider upon receipt of a properly completed claim. (b) Will not seek repayment from the provider in any instance in which the Medicaid overpayment is attributable solely to error in the state's determination of eligibility of a recipient. (7) Termination For Convenience. This agreement may be terminated without cause upon thirty (30) days written notice by either party. (8) Ownership. The provider agrees to give AHCA sixty (60) days written notice before making any change in ownership of the entity named in the provider agreement as the provider. The provider is required to maintain and make available to AHCA Medicaid-related records that relate to the sale or transfer of the business interest, practice, or facility in the same manner as though the sale or transaction had not taken place, unless the provider enters into an agreement with the purchaser of the business interest, practice, or facility to fulfill this requirement. (9) Comolete Information. All statements and information furnished by the prospective provider before signing the provider agreement shall be true and complete. The filing of a materially incomplete, misleading or false application will make the applicqtion and agreement voidable at the option of AHCA and is sufficient cause for immediate termination of the provide'r from the Medicaid program and/or revocation of the provider number. (10) Interpretation. This agreement shall not be construed against either party on the basis of this agreement having been prepared by one of the parties. (11) Governina Law. This agreement shall be governed by and construed in accordance with the laws of the State of Florida. (12) Amendment. This agreement, the application and other documents being executed and delivered pursuant hereto constitute the full and entire agreement and understanding between the parties hereto with respect to the subject matter hereof. No amendment shall be effective unless it is in writing and signed by each party. (13) Severability. If one or more of the provisions contained in this agreement or application shall be invalid, illegal or unenforceable, the validity, legality and enforceability of the remaining provisions shall not in any way be affected or impaired. (14) Aareement Retention. The parties agree that AHCA may only retain the signature page of this agreement, and that a copy of this standard provider agreement will be maintained by the Director of Medicaid, or his designee, and may be reproduced as a duplicate original for any legal purpose and may also be entered into evidence as a business record. (15) Fundina. This contract is contingent upon the availability of funds. MPA Revised July 1999 2 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: the undersigned have caused this agreement to be duly executed under the penalties of the foregoing is true and correct. Board of County Commissioners of Monroe County L. KOLHAGE, CLERK J-tc. t&,) ~ Deputy Clerk 10 -/ i- 0 '> Date Date Mayor (legibly print the above signature) Title (legibly print the above signature) Title Signature of Provider 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 !9lJlJ :;