3. 08/18/2004 Agreement
DANNY L. KOLHAGE
CLERK OF THE CIRCUIT COURT
DATE:
August 24,2004
TO:
Louis Latorre, Director
Social Services Division
ATTN:
Trish Barker
Bayshore Manor
Pamela G. Hanr>~
Deputy Clerk ry
FROM:
At the August 18, 2004, Board of County Commissioner's Meeting the Board granted
approval and authorized execution of the Institutional Medicaid Provider Agreement for Monroe
County to continue to participate in a Provider Agreement with the Florida Medicaid Program for
Assistive Care Services for residents of Bay shore Manor.
Enclosed is a certified copy of the above-mentioned for your handling. Should you have
any questions please do not hesitate to contact this office.
cc: County Administrator w/o document
County Attorney
Finance
File..!
INSTITUTIONAL
MEDICAID PROVIDER AGREEMENT
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 provider must deliver the services or goods to
eligible Medicaid recipients to receive payment from AHCA.
(3) Compliance. The provider agrees to comply. with local, state, and federal laws, as well as rules, regulations, and
statements of policy 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 are
met and remain in effect, this agreement shall remain ireffect for three (3) years from the effective date of the provider's
eligibility which is written in the 'Jffice area below unless otherwise terminated. This agreement is renewable only by
mutual consent. The provider understands and agrees that no AHCA signature is required to make this agr0ement valid
and enforceable. This agreement shall be accepted and entered into by AHCA upon the assignment of 2 provider number
and effective date as provided for herein.
(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 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, upon request or as required by applicable handbooks and 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 is
inseparable 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) Refund within 90 days of receipt any moneys received in error or in excess of the amount to which the provider is
entitled from the Medicaid program.
(g) To the extent allowed by in and accordance with section 768.28, F.S. (2001), and any successor legislation, 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 Institutional Revised April 2003
(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 to the extent AHCA permits or requires, co-payments, coinsurance, or deductibles will
recipients' pay 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.
U) 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 is terminable upon thirty (30) days written notice with or without cause
by either party.
,. "<:'('8) pwnership. The provider agrees to give AHCA sixty (60} days written notic~ before m.aking any change in ownership
o.t.the entity named in the provider agreement as the provider. The-pr.ovider is reqt.lired 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 pi,ce, unle!"s the provider enters into an agreement with the
. purchaser of the business interest, practice, or facility to fulfill th:s requ~rernent. Nilrsing facilities have the option to assign
this agreement to the new provider as a result of sale, lease, or any othei d1ange in operational ownership subject to all
i},'rms ar,;1 conditions under which the agreement was orig'nally !<;sued: !n tte eVE::1tof a change in Hospital .':\vmership,
'J":B new provider agrees to assume all liabilities ')uefrom prcviol!s provide!:: to ~;1::' 3gency, regarrlless.ofwhen the
liabili~jes ai'e identified in order to participate in t!le M.odlcaic.~ prngrar.1.
(9) ComPlete infNmc;,:;ion. Tile provider is requii"ed to furnist:;rue andc.ornplete statement::: and infomlation to AHCA
before signing the provider agreement. The provider is obligated to inform AHCA in writing of any change in the
statements and information prior to the change. The filing of a materially incomplete, misleading or false application will
make the application and agreement voidable at the AHCA's option and is sufficient cause immediate termination of the
provider from the Medicaid program and/or revocation of the provider's number.
(10) Interpretation. When interpreting this agreement, it shall be neither construed against either party nor considered
which party prepared the agreement.
(11) Governinq Law. The parties consent to governance by and interpretation of their agreement in accordance with the
State of Florida's laws.
(12) Amendment. This agreement, application and supporting documents constitute the full and entire agreement and
understanding between the parties with respect to their relationship. No amendment is 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 are declared invalid, then the
other provisions remain valid.
(14) Aqreement Retention. The parties agree that AHCA may only retain the signature page of this agreement, and that a
copy of this standard provider agreement is maintained by the Director of Medicaid, or his designee, and reproduced as a
duplicate original for any purpose and usable as evidence in any legal proceeding.
MPA Institutional Revised April 2003
2
(15) Funding. This contract is contingent upon the availability of funds.
(16) Assianability, The parties agree that neither may assign their rights under this agreement without the express written
consent of the other.
THE SIGNATORIES REPRESENT THAT THEY HAVE READ THE AGREEMENT, UNDERSTAND IT, AND ARE
AUTHORIZED TO EXECUTE IT ON BEHALF OF THEIR RESPECTIVE PRINCIPALS.
FOR OFFICE USE ONLY
The Provider entity name is: _Monroe County Bd Of County Commissioners_
The facility's d/b/a name is: _Bayshore Manor _
The provider number is:
140159900
The effective date of this agreement is: _September 1, 2004_
The termination date is: _August 31, 2007_
dates and numbe~s are added upon completion of enrollment)
IN WITNESS WHEREOF, the undersigned representative of the above executed this agr~ement :mder the penai:ry of
perjury and rlOW affj~l11s th~t the for&~oing;s true and correct.
~,,~ (~
- ~4.----____~____._
Signature ana Ti';~ of P~'~V'fj,,:!,:. ;;;:Jtl~Jrized RepresentativE:
08/ 18/?P04 __
Dat~:.,.
Murray E. Nelson, Mayor, Monroe County Board of County Commissioners
(You must legibly print or type the above signature and title.)
59-6000749
{You must legibly print or type your Federal Employer Identification Number (FEIN).}
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MP A Institutional Revised April 2003