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HomeMy WebLinkAbout20130479.tiffRESOLUTION RE: APPROVE PROFESSIONAL PROVIDER AGREEMENT FOR ACCOUNTABLE CARE COLLABORATIVE PROGRAM AND AUTHORIZE CHAIR TO SIGN - COLORADO ACCESS WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, on February 20, 2013, the Board was presented with a Professional Provider Agreement for the Accountable Care Collaborative Program between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and the Colorado Access, commencing upon full execution, and ending June 30, 2022, with further terms and conditions being as stated in said agreement, at which time the Board deemed it advisable to continue the matter to February 25, 2013, to allow additional time for review by the County Attorney, and WHEREAS, after review on February 25, 2013, the Board deems it advisable to approve said agreement, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Professional Provider Agreement for the Accountable Care Collaborative Program between the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Public Health and Environment, and Colorado Access be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said agreement. ce,//L 9- so- d0/3 2013-0479 HL0040 RE: PROFESSIONAL PROVIDER AGREEMENT FOR ACCOUNTABLE CARE COLLABORATIVE PROGRAM PAGE 2 The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 25th day of February, A.D., 2013. BOARD OF CO WELD CO ATTEST: William F. arcia, Chair Weld County Clerk to the Board TY COMMISSIONERS Nit COLORADO BY: Deputy Clerk unty Attorney rbara Kirkmeye Date of signature:MAR 0 1 2013 2013-0479 HL0040 COMMISSIONERS Memorandum TO: William F. Garcia, Chair Board of County Commissioners FROM: Mark E. Wallace, MD, MPH, Director Department of Public Health and Environment DATE: February 5, 2013 VbLt? COUNTY SUBJECT: Contract for Colorado Access with Health Care Policy & Financing (HCPF) Enclosed for Board review and approval is an updated contract between the Colorado Department of Health Care Policy & Financing ("HCPF") and the Board of County Commissioners of Weld County ("Board") on behalf of the Department of Public Health and Environment ("Department"). This updated contract is inclusive of language changes in the HCPF Volume 2.0 contract signed by the Board in September of 2012. HCPF is required to update the contract so the language and terms between the original contract and Volume 2.0 are consistent. This contract is for medical home and care management services for women served under the Department's Women's Health and Family Planning programs. The Department is currently reimbursed for eligible services through the Medicaid program under a master agreement with HCPF. If approved, the Department will receive a per member, per month payment for each eligible client enrolled in the program. Department staff members will continue to provide medical home, care navigation, referral management, and care coordination services to Medicaid. Beneficiaries enrolled in the program. The program is designed to improve quality while lowering costs of care by decreasing avoidable hospital admissions, preventable emergency Department visits, and utilization of high cost — low yield diagnostic tests. The Department would participate in the program in collaboration with area providers including Sunrise Community Health and Banner Health. The new term of this contract version 2.0 is until June 30, 2022, unless terminated earlier by either party. Funding for this contract depends on the number of clients who voluntarily enroll in the program. The Department will continue to receive $4 per member, per month. The Department anticipates serving less than 200 clients per month under the program. Enclosure 2013-04 }IA COLORADO ACCESS Professional Provider Agreement For Accountable Care Collaborative Program This Professional Provider Agreement ("Agreement") is made and entered into this 20 day of February 2013 by and between COLORADO ACCESS, a Colorado not -for-profit corporation ("Colorado Access"), and WELD COUNTY GOVERNMENT DBA WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT ("Provider"). WHEREAS, Colorado Access has entered into an agreement with the Colorado Department of Health Care Policy and Financing ("HCPF") to act as a Regional Collaborative Care Organization ("RCCO") for the HCPF Accountable Care Collaborative Program ("ACC Program"); WHEREAS, Provider has entered into an agreement with HCPF to serve as a Primary Care Medical Provider ("PCMP") for the HCPF ACC Program, and will be acting in such capacity within the geographical regions for which Colorado Access is serving as RCCO; WHEREAS, Colorado Access and Provider desire to enter in to this Agreement to facilitate Provider's ability to render Covered Services (defined below) to Members (defined below) who have been identified by HCPF as enrolled in the ACC Program and assigned or attributed to Provider; and WHEREAS, Provider expressly acknowledges that in rendering Covered Services to Members under this Agreement, it shall abide by all provisions of its own PCMP contract with HCPF (attached hereto and incorporated herein by reference as Attachment A), State and Federal Law, and all applicable rules and regulations established by HCPF and CMS. Provider further agrees to provide all data and information to Colorado Access as required by HCPF regulations and policies. NOW, THEREFORE, in consideration of the above recitals and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, Colorado Access and Provider agree as follows: A. DEFINITIONS Whenever used in this Agreement or its Attachments, Addenda or Appendices, the following terms shall have the indicated meaning: A. 1 Benefit Program (Line of Business). The RCCO program for the HCPF ACC Program through which Members are entitled to receive Covered Services. A. 2 Benefit Program Requirements. The rules, procedures, policies, protocols, legal and regulatory requirements, and other conditions to be followed by Colorado Access, Participating Providers, Provider Representatives, and Members regarding the Benefit Program. A. 3 Clean Claim. A claim with the required documentation timely submitted by a Participating Provider on a Uniform Claim Form with all required fields fully completed correctly, consistent with the provisions of C.R.S. § 10-16-106.5 and other applicable State and Federal Laws. A. 4 CLIA. The Clinical Laboratory Improvement Act of 1988, as amended. A. 5 Colorado Access Subsidiary. An entity or organization wholly owned, or controlled by Colorado Access. A. 6 Coordination of Benefits. The allocation of financial responsibility between two or more payers regarding Covered Services received by a Member. A. 7 Copavment. If required under the Benefit Program, that portion of the cost of Covered Services that a Member is obligated to pay directly to a Participating Provider or the State, or that another payer is contractually obligated to pay RCCO Professional Provider Agreement Revised May 201 I Page 1 of 15 a0/3-62/71 on behalf of a Member. including deductibles, coinsurance, and similar cost -sharing charges. Such cost may be a fixed dollar amount, a percentage amount, or a combination of the two. A. 8 Covered Services. Medically Necessary services that a Member is entitled to receive under the Benefit Program that are described and defined in the Benefit Program's Evidence of Coverage. or other similar disclosure forms issued to a Member and as may be amended and supplemented by Colorado Access or HCPF from time to time. A. 9 Drug Formulary. The list of medications eligible for coverage in conjunction with the Benefit Program as updated from time to time. A. 10 Emergency Medical Condition. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the Member (or, with respect to a Member who is a pregnant woman, the health of the Member and/or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. A. 11 Emergency Services. Covered Services required by a Member that are furnished by a Provider qualified to furnish or provide emergency medical services and needed to evaluate or stabilize an Emergency Medical Condition. A. 12 Federal Health Program. Medicare. Medicaid, TRICARE, Veteran's Administration, Public Health Service, Indian Health Service, and children's health insurance under Title XXI of the Social Security Act, and any future health related programs developed and funded by the federal government. A. 13 HIPAA. The federal Health Insurance Portability and Accountability Act of 1996 and associated implementing regulations and standards, as amended periodically by the federal government. A. 14 Material Change. A change to this Agreement that decreases Provider's compensation for Covered Services, modifies Benefit Program Requirements in a way that may reasonably be expected to significantly increase Provider's administrative expenses, or adds a new category of service. A Material Change is further defined in Colorado Revised Statutes § 25-37-102. A. 15 Medically Necessary. A Covered Service shall be deemed Medically Necessary in accordance with the Provider's direct agreement with HCPF for fee for service Colorado Medicaid. A. 16 Member. An individual entitled to have Covered Services provided or arranged through the Benefit Program. A. 17 Participating Provider. The Provider who has this Agreement with Colorado Access to provide Covered Services to Members. A. 18 Payer. PCMP claims shall be reimbursed directly by HCPF in accordance with the terms of Provider's direct agreement with HCPF for fee for service Colorado Medicaid. A. 19 Primary Care Medical Provider ("PCMP"). A primary care provider, including Provider, who serves as a Medical Home for Members and may be an FQHC. RHC, clinic or other group practice that provides the majority of a Member's comprehensive primary, preventive and sick care. Individual PCMPs or pods can be physicians, advanced practice nurses, or physician assistants with a focus on primary care, general practice, internal medicine, pediatrics, geriatrics or obstetrics and gynecology. A. 20 Prior Authorization. When required under the Benefit Program or associated Utilization Management Program, the unique authorization to be obtained from HCPF or its designee by a Member's PCMP, or by a Participating Provider, Provider Representative, or other health care provider prior to admitting a Member to a hospital or providing certain other Covered Services to a Member. A. 21 Provider Representative. A physician, allied health professional. or other health care provider who has a direct or indirect contract with Provider, or is employed by Provider. A. 22 Quality Management Program. The functions, including, but not limited to, credentialing and certification of providers, review and audit of medical and other records. outcome rate reviews, peer review, and provider appeals and grievance KCVO Professional Provider Agreement Revised May 2011 Page 2 of 15 procedures performed or required by Colorado Access, HCPF, or any other permitted person or entity, to review and improve the quality of Covered Services rendered to Members. A. 23 Referral. As required by the Benefit Program or associated Utilization Management Program, the process by which a Member's PCMP or Provider Representative directs a Member to seek and obtain Medically Necessary services from another Participating Provider or specialist. A. 24 State and Federal Law. The laws and regulations of the State of Colorado or of the United States of America that apply to Colorado Access, HCPF, Provider, Provider Representatives, and this Agreement. A. 25 Uniform Claim Form. A claim form submitted on Form CMS -1500 or Form CMS -1450 (UB-04), or the equivalent, and also electronic claims populated with similar information in HIPAA-compliant format, as required by State and Federal Law. A. 26 Utilization Management Program. The functions, including but not limited to Prior Authorization, and prospective, concurrent, and retrospective review, performed or required by HCPF to review and determine whether medical services or supplies provided to Members, or proposed to be provided to Members, are covered under the Benefit Program and meet the definition of Medically Necessary services. B. PROVIDER REPRESENTATIONS AND RESPONSIBILITIES B. 1 Provision of Covered Services. Provider agrees to provide or arrange for, and to ensure that any Provider Representatives provide and arrange for, Covered Services to Members in accordance with: (a) The terms and conditions of this Agreement; (b) State and Federal Law; (c) The Utilization Management Program, Quality Management Program, Benefit Program Requirements, and grievance, appeals, and other policies and procedures of the Benefit Program; (d) Standards requiring services to be provided in the same manner, and with the same availability, as services provided to other patients; and (e) The clinical quality of care and performance standards that are recognized by HCPF, including those contained in Attachment A. B. 2 Offices and Hours. Provider shall maintain such offices, equipment, patient service personnel, and allied health personnel as may be necessary to provide Covered Services under this Agreement and Attachment A. B. 3 Coverage. Provider shall ensure that each Provider Representative arranges for coverage by a Participating Provider in the event of his/her illness, vacation, or other absence in accordance with HCPF's standards. B. 4 Representations of Provider. At all times during the term of this Agreement, Provider represents and warrants that: (a) If a legal entity, Provider is organized, validly existing. and in good standing under State and Federal Law; (b) Provider has the authority to execute and perform the obligations of this Agreement; (c) Provider holds all necessary registrations, permits, licenses, and other approvals required by State or Federal Law to perform the obligations of this Agreement; (d) Provider's organizational documents, and any separate agreement to which Provider is a party. do not conflict with this Agreement; (e) Provider shall utilize its best efforts to ensure that all Provider Representatives comply with the applicable terms of this Agreement. including the obligations of Provider; and (0 Provider will not act in a manner that will cause the Provider to be investigated, arrested, sanctioned, debarred or excluded by authorized State and Federal law enforcement, regulatory or licensing agency. B. 5 Requirements for Provider Representatives. Provider represents and warrants that, at all times during the term of this Agreement, each Provider Representative shall: (a) Be duly licensed, certified, or otherwise authorized to provide Covered Services; (b) Hold active staff privileges on the medical staffs of hospitals that are Participating Providers, if required by Colorado Access or HCPF; RCCO Professional Provider Agreement Revised May 2011 Page 3 of 15 (c) Hold a current Drug Enforcement Agency narcotic registration certificate, where applicable; (d) Maintain a professional relationship with each Member for whom Provider Representative provides Covered Services; (e) Have professional liability insurance equal to, or in excess of. the minimum policy limits required by this Agreement, State and Federal Law; (f) Comply with this Agreement. State and Federal Law, and Attachment A in the provision of Covered Services; (g) Comply with all credentialing standards and requirements established by HCPF for Participating Providers; and (h) Ensure that it will not act in a manner that will cause the Provider Representative to be investigated, arrested, sanctioned, debarred or excluded by authorized State and Federal Law enforcement, regulatory or licensing agencies. B. 6 Restriction, Suspension, or Termination of Provider Representatives. Provider shall immediately restrict, suspend, or terminate any Provider Representative from providing Covered Services if: (a) A Provider Representative fails to meet the requirements described above in Section B.5; (b) Any of the events described in Section B.8 occur with regard to a Provider Representative; (c) Provider, HCPF or Colorado Access reasonably determines that there exists material deficiencies in the professional competence, conduct, or quality of care of the Provider Representative that adversely affects, or could adversely affect, the health or safety of a Member or the reputation of HCPF or Colorado Access; and (d) Colorado Access requests that the Provider restrict, suspend, or terminate the Provider Representative from providing Covered Services. B. 7 Prompt Notice of Material Events. Provider shall notify Colorado Access in writing immediately after Provider becomes aware of: (a) Provider's failure to satisfy the representations described above in Section B.4; (b) A Provider Representative's failure to meet the requirements described above in Section B.6; (e) The commencement of any investigation, action, or proceeding against Provider or a Provider Representative by any State or Federal licensing or certifying agency or board; (d) A Provider Representative's failure to comply with all applicable Quality Management Programs or Utilization Management Programs; (e) Provider's or a Provider Representative's failure to maintain any insurance coverage required by this Agreement; (f) Provider's or a Provider Representative's indictment, arrest, or conviction for any criminal charge related to the provision of health care services; (g) The exclusion or threatened exclusion of Provider or a Provider Representative from any State or Federal health care program; (h) Provider's or a Provider Representative's voluntary opting -out of participating in programs operated under the Centers for Medicare and Medicaid Services; or (i) Any event that would materially impair Provider's or a Provider Representative's ability to provide Covered Services under this Agreement. B. 8 Timely Notice of Actions and Changes of Ownership. Provider shall forward to Colorado Access, within 2 business days of Provider's knowledge or receipt of: (a) Any written complaint, grievance, investigation, malpractice suit, arbitration action, appeal, or any other civil or criminal action against or involving Provider, a Provider location, or a Provider Representative that materially affects the performance of this Agreement; or (b) Any material change in the ownership or business operations of Provider or its Provider location that materially affects the performance of this Agreement. B. 9 Subcontracting. Every subcontract regarding the provision of health care services and supplies between Provider and a subcontractor, including an independent contractor Provider Representative, shall comply with State and Federal Law and have terms and conditions that arc consistent with this Agreement and Attachment A. Provider shall, upon request, furnish to Colorado Access copies of such subcontracts within 10 calendar days. If applicable, each such subcontractor shall meet HCPF's credentialing requirements before the provision of Covered Services. Provider shall be solely responsible for payment of any subcontractors allowed under this Agreement, and Provider agrees to indemnify, hold RCCO Professional Provider Agreement Revised May 2011 Page 4 of 15 harmless, and defend Colorado Access, HCPF, and Members from and against any and all claims that may be made by such subcontractors in connection with the provision of Covered Services to Members. B. 10 Quality Management Program. Provider and/or Provider Representatives shall be solely responsible for the quality of Covered Services provided by them to Members. The quality of such services shall be monitored under the applicable Quality Management Program, and Provider agrees, among other things, to: (a) participate in, and cooperate with, all aspects of the ACC Program, including cooperation with Colorado Access as the RCCO; (b) comply with all decisions or recommendations made in writing by Colorado Access or HCPF in connection with the ACC Program provided that any decisions regarding any Members' treatment or health care remain the sole decision of Provider and/or Provider Representatives; (c) provide all requested information relating to Members' care to Colorado Access or HCPF to ensure compliance with the ACC Program's Medical Home Model principles; and (d) provide data and other information as required or requested by Colorado Access or HCPF under the ACC Program. If the quality of care furnished by Provider or Provider Representative is found to be unacceptable under the applicable Quality Management Program, Colorado Access or HCPF shall give written notice to Provider to correct the specified deficiencies within the time period specified in the notice. Provider agrees to correct such deficiencies within the time period specified in the notice. If Provider fails to correct the specified deficiencies within the specified time period, the provider may be subject to corrective action including but not limited to termination in accordance with Section D below. B. 11 Utilization Management Program. Provider agrees to participate in, cooperate with, and comply with all Utilization Management decisions, policies and/or processes in connection with the Benefit Program. Provider also agrees to provide to Colorado Access or HCPF such records and other information reasonably requested under the applicable Utilization Management Program within the timeframe specified for the Benefit Program. If the Provider fails to respond to reasonable requests within the timeframe specified for the Benefit Program, Provider may be subject to corrective action including but not limited to termination in accordance with Section D below. B. 12 Prior Authorization. Except for Emergency Services, or unless the Benefit Program or its associated Utilization Management Program specifies otherwise, and for all Covered Services that require Prior Authorization, Provider agrees not to seek payment from HCPF for Covered Services provided to a Member without first obtaining Prior Authorization. B.13 Referral to Participating Providers or Specialists. If Provider determines that a Member requires services not within Provider's scope of services, regardless whether for inpatient, outpatient, physician, ancillary, or other types of services, Provider agrees to refer, and agrees to ensure that Provider Representatives refer, the Member to a Participating Provider or specialist in accordance with the ACC Program referral guidelines and contract terms. B. 14 Drug Formulary. Provider shall also comply, and ensure that its Provider Representatives comply, with HCPF's policies and procedures for obtaining coverage for non -formulary medications, restricted formulary medications and all other matters related to the provision of pharmacy services. B. 15 Insurance. Provider shall maintain insurance policies, issued by one or more insurance companies licensed to do business in Colorado, with policy limits equal to, or in excess of, the minimum amounts required by State and Federal Law or the amount specified below, whichever is greater. Provider agrees to provide to Colorado Access written evidence of such insurance coverage within 3 calendar days of request by Colorado Access. Provider also agrees to notify, or to ensure that its insurance carriers notify, Colorado Access at least 30 calendar days before any proposed termination, cancellation, or material modification of any insurance policy specified below. Provider shall maintain the following insurance policies for insurance coverage of activities performed in connection with this Agreement: (a) Professional liability insurance that meets the requirements of the Colorado Health Care Availability Act, as amended; (b) Comprehensive general liability insurance covering claims for damages arising out of premises liability, personal injury liability, and contractual liability, with minimum policy limits of $600,000 per occurrence and $1,000,000 in the aggregate of all claims per policy year; and (c) Workers' compensation insurance covering all employees. Provider shall ensure that Provider Representatives and Provider's subcontractors who perform services in connection with this Agreement and who are not insured under Provider's insurance policies shall maintain the same insurance coverage required of Provider under this Section unless otherwise permitted by HCPF in writing. All insurance required under this Agreement shall be provided by insurers who have an A.M Best's rating of A: VIII or better. RCCO Professional Provider Agreement Revised May 201 I Page 5 of 15 B. 16 Grievance System. Provider shall comply with the Benefit Program's Member grievance procedures. B. 17 Advance Directives. Provider shall abide by a Member's advance directives regarding life -sustaining treatment in accordance with State and Federal Law. Provider shall prominently document in each Member's medical record whether or not the Member has executed an advance directive. B. 18 New Members. Provider agrees to provide services to new Members pursuant to the ACC Program guidelines and contract terms, and all applicable State and Federal laws and regulations. B. 19 Expenditures of Federal Assistance. Provider and Provider Representatives agree to notify the Colorado Department of Health Care Policy and Financing when expected or actual expenditures of federal assistance from all sources equal or exceed $500,000. The Office of Management and Budget (OMB) Circular No. A-133, Audits of States, Local Governments, and Non -Profit Organizations, defines audit requirements under the Single Audit Act of 1996 (Public Law 104-156). All state and local governments and non-profit organizations expending $500,000 or more from all sources (direct or from pass -through entities) are required to comply with the provisions of Circular No. A-133. The Circular also requires pass -through entities to monitor the activities of subrecipients and ensure that subrecipients meet the audit requirements. C. COMPENSATION C. I Compensation Rates. Provider acknowledges and understands that Colorado Access does not provide any payment to Provider or Provider Representatives. Rather, all Primary Care Case Management medical claims shall be reimbursed directly by HCPF. Provider and its Provider Representatives shall accept as payment in full for Covered Services, and all other services rendered to Members under this Agreement, the amounts payable by HCPF in accordance with Attachment A and Provider's direct agreement with HCPF for fee for service Colorado Medicaid. Provider shall bill and accept payment for Covered Services rendered by its Provider Representatives, and be responsible for administering such funds and compensating its Provider Representatives, in accordance with the same compensation terms applicable to Provider herein. C. 2 Billing and Payment. (a) Billing. Provider shall submit on a Uniform Claim Form, by electronic claims submission or hard copy, Clean Claims in a format approved by HCPF for Covered Services provided to a Member within the timelines specified by HCPF. Where Colorado Access is the secondary payer under Coordination of Benefits, a claim must be received by Colorado Access within 120 calendar days of the date that HCPF issues its remittance advice. Provider shall not seek payment from any Member in the event Colorado Access or HCPF fails to pay Provider for a claim not timely submitted. (b) Payment. HCPF shall make payment on, deny, or settle each of Provider's Clean Claims timely submitted in accordance with the timelines specified by HCPF. Penalties for noncompliance shall be as set forth in State and Federal Law. C. 3 Eligibility. Provider shall verify the eligibility of Members before providing Covered Services in accordance with the terms and conditions established by HCPF. C. 4 Collection of Copayments. Members who are enrolled with the Colorado Medicaid program shall not be liable for Copayments when the State is responsible for paying such amounts. C. 5 No Surcharges. Provider shall not charge a Member any fees or surcharges for Covered Services except for authorized Copayments. In addition, Provider shall not collect sales, use, or other applicable taxes from Members for the sale or delivery of medical services. If Colorado Access or HCPF receives notice of any additional charge, Provider shall fully cooperate with Colorado Access or HCPF to investigate such allegations, and shall promptly refund any payment deemed improper by Colorado Access or HCPF to the party who made the payment. C. 6 Member Hold Harmless. Provider agrees that, in no event, including nonpayment by HCPF or any other payer, the insolvency of Colorado Access, or breach of this Agreement by any party, shall Provider bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against Members or persons other than HCPF or another appropriate payer. This provision shall not prohibit collection of Copayments on in accordance with the terms of the Benefit Program. Provider further agrees that this provision: (a) shall survive the termination of RCCO Professional Provider Agreement Revised May 2011 Pagc 6 of 15 this Agreement regardless of the cause giving rise to termination; (b) shall be construed for the benefit of Members; and (c) supersedes any oral or written contrary agreement now existing or hereafter entered into between Provider and Members or persons acting on their behalf. C. 7 Conditions for Compensation of Non -Covered Services. Provider may bill a Member for non -Covered Services rendered by Provider to such Member only if the Member is specifically notified in advance that the specific services to be provided are not covered under the Member's Benefit Program, and the Member nonetheless requests in writing that Provider render the specific non -Covered Services, prior to Provider's rendition of such services. This notification must be signed by each applicable Member for each applicable service. For purposes of this provision, a general waiver under which a Member acknowledges he/she may be responsible for payment in the case of non-payment by a carrier is not sufficient. C. 8 Patients Who Are Not Members. This Agreement does not apply to services rendered to patients who are not Members at the time the services are rendered, except as provided in Section D.6 below. C. 9 Coordination of Benefits. Provider agrees to abide by the Coordination of Benefits policies and procedures established by HCPF for the Benefit Program. Provider shall not bill Members for any portion of Covered Services not paid by the primary carrier when HCPF is the secondary carrier, but shall instead look to the secondary carrier for such payment. When a Member has coverage which is primary through another carrier, HCPF's compensation to Provider shall be the difference between the amount paid by the primary payer and total billed charges, limited to the fee for service Colorado Medicaid negotiated rates applicable to this Agreement and Attachment A. C. 10 Third Party Recoveries. When HCPF has compensated Provider for Covered Services, then HCPF retains the right to recover from applicable third party carriers covering a Member, including self -insured plans and other third party sources, and to retain all such recoveries. Provider agrees to provide Colorado Access with such information as Colorado Access may require for IICPF to pursue recoveries from such third party sources and to promptly remit to HCPF any monies Provider may receive from, or on behalf of, such sources of recovery. C. 1 I Overpayments. Unless required by State or Federal Law, HCPF or Colorado Access shall have the right to periodically audit Provider's records to assure appropriate reimbursement. HCPF or Colorado Access shall recoup amounts paid to the Provider in error for a period in accordance with the timelines established by HCPF. Unless required by State or Federal Law, error may be a process error on the part of HCPF, the Provider, or otherwise. Error includes, but is not limited to, inappropriate charges, lack of eligibility, or computer error. C. 12 Laboratory Testing. Provider agrees to comply with the Public Health Service Act (42 U.S.C. § 263a) as revised by the Clinical Laboratory Improvement Amendments ("CLIA") of 1988 or. in the alternative, shall provide Colorado Access with a Certificate of Waiver as issued by the Department of Health and Human Services with regard to Provider location as applicable. D. TERM AND TERMINATION D. 1 Term. Provided that the provisions of this Agreement have been met, the term of this Agreement shall commence on the date set forth on the first page of this Agreement and it shall continue in effect for successive annual periods, unless one party notifies the other in writing of its intent not to renew this Agreement at least 120 calendar days before the next scheduled renewal date. D. 2 Immediate Termination. Colorado Access may terminate this Agreement or any individual Provider Representative's participation under this Agreement immediately upon notice to Provider in the event of: (a) Provider's violation of any applicable State or Federal Law; (b) Provider's failure to maintain the professional liability insurance coverage specified hereunder; (c) Provider's exclusion or voluntary exclusion from State or Federal programs; (d) Colorado Access' determination that the health, safety, or welfare of any Member may be in jeopardy if this Agreement is not terminated, or (e) Provider's notice or failure to provide notice under Section B.7 or Section B.8 above, or Section D.6 below. D. 3 Termination Due to Material Breach. In the event that either Provider or Colorado Access fails to cure a material breach of this Agreement within 30 calendar days of receipt of written notice to cure, the non -defaulting party may terminate this Agreement effective as of the expiration of said 30 -day period. If the breach is cured within such 30 -day RCCO Professional Provider Agreement Revised May 2011 Page 7 of 15 period, or if the breach is one which cannot reasonably be cured within 30 calendar days, and the non -defaulting party determines that the defaulting party is making substantial and diligent progress toward correction during such 30 -day period, this Agreement shall remain in full force and effect. Examples of material breach include but are not limited to (1) Provider's failure to abide by the terms and conditions set forth in Attachment A, , and (2) Provider's failure to comply with the terms, conditions or determinations of any Utilization Management Program, Quality Management Program, or other Benefit Program Requirements. D. 4 Termination without Cause. Either party may terminate this Agreement without cause upon written notice to the other party at least 120 calendar days before the termination effective date. D. 5 Immediate Termination. Colorado Access reserves the right to immediately terminate this Agreement if the State or Federal government terminates the Benefit Program or Colorado Access' participation in that program. D. 6 Termination or Suspension of Provider in ACC Program. If for any reason Provider's direct contract with HCPF as a PCMP within the ACC Program is terminated or suspended, Provider shall provide written notification to Colorado Access within five (5) calendar days of Provider's receipt of such termination or suspension. Colorado Access shall be responsible for notifying Members who have selected or been assigned to Provider of Provider's suspension or termination in accordance with 42 C.F.R. 438.10(1)(5). D. 7 Continuity of Care. In the event that a Member is receiving Covered Services at the time this Agreement terminates, Provider shall continue to provide Covered Services to the Member until: (a) The Member is assigned to another Participating Provider (with which Provider shall cooperate); (b) The Member is discharged from an inpatient facility, if an inpatient on the date of termination; (c) Conclusion of an active treatment regimen, or up to 60 calendar days, unless otherwise specified in the Benefit Program requirements, if the Member is receiving active treatment from Provider for a chronic or acute medical condition; (d) The postpartum period for Members in their second or third trimester of pregnancy; or (e) The Member is no longer a Member. Compensation for such Covered Services shall be at the rates applicable to Attachment A for the Benefit Program. E. AMENDMENTS AND CHANGES E. 1 Material Changes. Colorado Access may make a Material Change to this Agreement by giving to Provider 90 days advance written notice of the Material Change. Such notice shall be conspicuously entitled "Notice of Material Change." If Provider objects in writing to the Material Change within 15 calendar days of the notice, and there is no resolution of the objection by mutual agreement between Colorado Access and Provider, either party may terminate this Agreement upon written notice of termination provided to the other party. Such notice of termination shall not be effective unless given at least 60 calendar days before the effective date of the Material Change. If Provider does not so object to the Material Change, the Material Change shall be effective as specified in the "Notice of Material Change." If a Material Change is the addition of a new category of coverage and Provider so objects, the addition shall not be effective as to Provider, and the objection shall not be a basis upon which Provider may terminate this Agreement. E. 2 Non -Material Changes. Pursuant to Colorado Revised Statutes $ 25-37-102(9)(b), Colorado Access may make a non - Material Change to this Agreement by giving to Provider a written notice of the non -Material Change. Such non - Material Change shall be effective 15 calendar days after Colorado Access' issuance of such notice unless another later effective date is set forth in such notice. Examples of non -Material Changes include but are not limited to (1) changes to an existing prior authorization, notification, or referral program that do not substantially increase the Provider's administrative expense, and (2) a decrease in payment or compensation resulting solely from a change in a published fee schedule. E. 3 Changes Required by State and Federal Law. Amendments mandated because of legislative or regulatory changes made by State and Federal government agencies may not require the consent of Provider and /or Colorado Access. Such amendments will be effective on the effective date established by such government agencies. Any amendment to this Agreement requiring prior approval of, or notice to, any State or Federal agency shall not become effective until all necessary approvals have been granted or all required notice periods have expired. RC('O Professional Provider Agreement Revised May 2011 Page 8 of 15 F. ACCESS TO AND CONFIDENTIALITY OF RECORDS F. 1 Medical and Other Records. Provider warrants that it prepares and maintains, and will continue to prepare and maintain, all medical and other records required by State and Federal Law in accordance with the general standards, including, but not limited to, accuracy and privacy standards, applicable to such records. Provider and any subcontractor shall maintain such financial, administrative, and other records as may be necessary for compliance by Colorado Access, HCPF and/or the ACC Program, and in accordance with State and Federal Law. F. 2 Access to Records; Audits. The records referred to in Section F.1 shall be and remain the property of Provider and/or any subcontractor(s), and shall not be removed or transferred from Provider or any subcontractor(s) except in accordance with HIPAA and other State and Federal Law. Subject to such laws, Colorado Access and HCPF, or their designated representatives, and designated representatives of any government agency having jurisdiction over Colorado Access or HCPF, shall have reasonable access to Provider's records or the applicable records of any subcontractors at Provider's or subcontractor's place of business during normal business hours, to review and make copies of such records. Such governmental agencies shall include the Colorado Department of Public Health and Environment, the Colorado Department of Health Care Policy & Financing, the Colorado Division of Insurance, the United States Department of Health and Human Services, and their designees. Additionally, Provider agrees to permit Colorado Access. its designated representatives, and designated representatives of such government agencies to conduct site evaluations and inspections of Provider's and/or any of its subcontractor's offices and service locations. Pursuant to 42 CFR * 422.504(d) -(e), Provider shall keep all records related to performance under this Agreement for 10 years unless otherwise required by State and Federal Law. F. 3 Confidentiality. In accordance with the requirements set forth in HIPAA, Provider and Colorado Access during and after the term of this Agreement shall keep confidential any information regarding the diagnosis, treatment, or health of any Member. Confidential data and information means any information in a form identifiable with the Member, including but not limited to, Member medical records, quality improvement information, utilization review information, statistical data, and reports, whether oral, written, or electronic. Colorado Access and Provider agree that nothing in this Section shall be construed as a limitation of the Provider's right or obligation to discuss with the Members matters pertaining to their health. Provider acknowledges that access to the Colorado Access on-line services system and the information it contains is confidential. Provider also warrants that access to the Colorado Access on-line services system is restricted to the authorized users of the system. Any breach of this section may result in the loss of access to the system. F. 4 Copy Charges. When requested by Colorado Access or representatives of local. state or federal regulatory agencies, Provider, Provider's Representatives and/or any subcontractor(s) shall produce copies of any Medical or Other Records as outlined in Section F.1 at the State prevailing rate as set forth in 6 CCR 1011-1, Chapter II 5.2.3.4. In no event shall Colorado Access be responsible for other costs or fees associated with any audit. Additionally, Colorado Access shall not reimburse Provider or Provider Representatives for copies of medical or other records related to the RCCO or ACC Program. Colorado Access agrees to reimburse Provider for medical or other records related to any quality management review. G. MISCELLANEOUS G. 1 INDEPENDENT CONTRACTOR STATUS. Provider shall perform its duties hereunder as an independent contractor and not as an employee of Colorado Access. Neither Provider nor any agent or employee of Provider shall be. or shall be deemed to be, an agent or employee of Colorado Access. Provider shall pay, when due, all required employment taxes, income taxes, and local taxes on any money paid pursuant to this Agreement. Provider acknowledges that Provider and its employees are not entitled to unemployment insurance benefits unless Provider or a third party provides such coverage, and that Colorado Access does not pay for or otherwise provide such coverage. Provider shall have no authorization, express or implied. to bind Colorado Access to any agreements, liabilities, or understandings except as expressly set forth in this Agreement. G. 2 Payment of Applicable Taxes. Provider shall be solely responsible for the collection and payment of any sales, use or other applicable taxes on the sale or delivery of medical services. RCCO Professional Provider Agreement Revised May 20 I Page 9 of 15 G. 3 Right to Disagree Concerning Medical Decisions, Policies, or Practices. In accordance with Colorado Division of Insurance Regulation § 4-2-17: (a) No Provider or Provider Representative shall be prohibited from protesting or expressing disagreement with a medical decision, medical policy, or medical practice of Colorado Access or an entity representing or working for Colorado Access. (b) Colorado Access, or an entity representing or working for Colorado Access, shall not be prohibited from protesting or expressing disagreement with a medical decision, medical policy, or medical practice of a Provider or Provider Representative. (c) Colorado Access shall not terminate this Agreement because a Provider or Provider Representative expresses disagreement with a decision by Colorado Access, or an entity representing or working for Colorado Access, to deny or limit benefits to a Member or because the Provider or Provider Representative assists the Member to seek reconsideration of Colorado Access' decision, or because a Provider or Provider Representative discusses with a current, former, or prospective patient any aspect of the patient's medical condition, any proposed treatments or treatment alternatives, whether a Covered Service or not, or policy provisions of Colorado Access, or a provider's personal recommendation regarding selection of a health plan based on the provider's personal knowledge of the health needs of such patients. G. 4 Non -solicitation for Discontinuance of Participation. Provider and its employees, agents, and subcontractors shall not solicit, or attempt to convince, any Member not to participate or to discontinue participation in the Benefit Program for which Provider renders Covered Services under this Agreement. G. 5 Nondiscrimination. Provider agrees that, in providing services, Provider shall comply with the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, and all related implementing regulations. Provider shall not discriminate against any Member on the basis of race, color, religion, sex, national origin, age, health status, participation in any government program (including Medicaid and Medicare), source of payment, participation in a health plan, marital status, or physical or mental disability. Nor shall Provider knowingly contract with any person or entity which discriminates against any Member on such basis. G. 6 Listing of Information. Both parties agree that Colorado Access and Provider may list the name, address, telephone number and other factual information of Colorado Access, Provider, Provider location, Provider Representatives, and Provider's subcontractors in its marketing and informational materials. Either party shall supply all printed materials and other information relating to its operations within 7 calendar days of request by the other party. G. 7 Marketing. All marketing materials including, but not limited to, brochures, pamphlets. or benefit plan and enrollment information with either parties name on it, must be approved by the other party. G. 8 Assignment. Provider may not assign this Agreement. or its respective rights and obligations under this Agreement, without the prior written consent of Colorado Access. Such consent shall not be unreasonably withheld by Colorado Access. G. 9 Confidentiality of Proprietary Information. Colorado Access and Provider agree to hold all confidential or proprietary information or trade secrets of each other in trust and confidence and agree that such information shall be used only for the purposes contemplated in this Agreement, and not for any other purpose. Specifically, Colorado Access and Provider shall keep strictly confidential all compensation rates set forth applicable to this Agreement and Attachment A, except that this provision does not preclude disclosure of the method of compensation (e.g., fee -for -service, capitation, shared risk pool, DRG, per diem, etc.), unless otherwise required by State or Federal Laws. G. 10 Dispute Resolution. Provider and Colorado Access agree to meet and confer in good faith to resolve any problems or disputes that may arise under or relate to this Agreement. Negotiation shall be a condition precedent to the filing of any arbitration demand by either party. If the parties are unable to resolve any significant dispute within 60 calendar days following the date one party sent written notice of the dispute to the other party. and if either party then decides to pursue the dispute, the dispute shall thereafter be submitted to binding arbitration through the American Arbitration Association under its Commercial Arbitration Rules, with the arbitration to be held in Denver, Colorado. Judgment on the award rendered by the arbitrator may be entered in any court of competent jurisdiction. Arbitration shall be initiated by either party by making a written demand for arbitration on the other party. The arbitrator shall have the power to RUC() Professional Provider Agreement Revised May 201 I Page 10 of 15 resolve all disputed issues, including questions concerning the enforceability of this Agreement and whether the dispute is subject to arbitration. The arbitrator shall also have the power to make interim awards (e.g., temporary restraining orders, preliminary injunctions, etc.). No party shall be able to recover any exemplary or punitive damages. Unless otherwise agreed by the parties in writing, the party wishing to pursue the dispute must initiate the arbitration within one year after the date on which notice of the dispute was given or that party shall be deemed to have waived its right to pursue the dispute in any forum. Except for termination pursuant to Section D.2 of this agreement, during the arbitration proceedings, Provider shall continue to provide Covered Services to Members and Colorado Access shall continue to make any undisputed payments to Provider in accordance with this Agreement. G. 11 Entire Agreement. This Agreement supersedes any and all other agreements, either oral or written, between the parties with respect to the subject matter hereof, and no other agreement, statement or promise relating to the subject matter of this Agreement shall be valid or binding. G. 12 Survival. The following Sections of this Agreement shall survive any termination of this Agreement: Section A, Section C, Section D.7, Section F, Sections G.2 through G.7, Sections G.9 through G.12. and Sections G.15, G.16, G.18. G.19, G.20, and G.22 through G.24. G. 13 Non -Exclusive Agreement. This Agreement is non-exclusive and shall not prohibit Provider or Colorado Access from entering into other agreements with other health care providers or purchasers of health care services. G. 14 No Third Party Rights. Nothing in this Agreement is intended to, or shall be deemed or construed to create any rights or remedies in any third party, including Members and Provider Representatives. Nothing contained herein shall operate (or be construed to operate) in any manner whatsoever to increase the rights of any such Members or the duties or responsibilities of Provider or Colorado Access as to such Members. G. 15 Notices. Any notice required or desired to be given under this Agreement shall be in writing and shall be sent by certified mail, return receipt requested, postage prepaid, or overnight courier, or fax, addressed as follows. The addresses to which notices are to be sent may be changed by written notice given in accordance with this Section. Colorado Access: Provider: Colorado Access ATTN: Director Provider Network Services PO Box 17580 10065 East Harvard Avenue #600 Denver, Colorado 80217-0580 Fax number: (303) 755-2368 Weld County Government ATTN: 1555 North 17th Avenue Greeley, CO 80631 Fax number: G. 16 Severability. If any provision of this Agreement is rendered invalid or unenforceable by any local, state, or federal law, rule or regulation, or declared null and void by any court of competent jurisdiction, the remainder of this Agreement shall remain in full force and effect. G. 17 Addenda. Attachment A to this Agreement is made a part of this Agreement as though set forth fully herein. Any provision of Attachment A that is in conflict with any provision of this Agreement shall take precedence and supersede the conflicting provision of this Agreement. In all other respects, this Agreement shall remain in full force and effect. G. 18 Governing Law. This Agreement shall be governed by and construed and enforced in accordance with the laws of the State of Colorado without regard to conflicts of laws principles, except to the extent such laws conflict with, or are preempted by, federal law, in which case such federal law shall govern. G. 19 Liability for Own Acts. Each party shall be solely responsible for all direct, compensatory, special, indirect, incidental, consequential, punitive, and other damages of every type, which are assessed against and/or incurred by such party, whether by verdict, settlement, or otherwise, and which arise out of or result from: (a) the acts or omissions of such RCCO Professional Provider Agreement Revised May 2011 Page 11 of 15 party or its employees or subcontractors; (b) any breach by such party of any duty or obligation arising under this Agreement; and/or (c) any violation by such party of State and Federal Law or any judicial or administrative order. G. 20 Federal Fund Disclosure. (a) No federal appropriated funds have been paid or will be paid by, or on behalf of, Provider to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress. or an employee of a member of Congress in connection with the awarding of any contract. This includes the extension, continuation, renewal, amendment, or modification of any contract, grant, loan or cooperative agreement that utilizes federal funds. (b) If any funds other than federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress, an officer or employee of Congress in connection with this federal contract, grant, loan, or cooperative agreement, Provider shall complete and submit Standard Fonn - LLL, "Disclosure of Lobbying Activities" in accordance with its instructions. (c) The Provider agrees that it shall include the language of this Section G. 20 in all subcontracts, subgrants, and contracts under grants. loans, and cooperative agreements. Provider shall require that all subrecipients certify and disclose accordingly. Furthermore, this certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31 U.S. Codc. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. G. 2I Fraud and Compliance IIotline. Provider should report issues of suspected or potential fraud to the Colorado Access Compliance Hotline (877-363-3065) or the Colorado Access Compliance Officer. Such reports may be made anonymously and/or the reporting individual or party may request confidentiality. Provider must make reasonable efforts to assist in detecting, reporting, and preventing false claims and other fraudulent or abusive practices. G. 22 Compliance with Laws. Colorado Access and Provider shall comply with all relevant State and Federal Laws, local laws, statutes, ordinances, orders and regulations applicable to the terms and conditions of this Agreement and all requirements set forth under the Medicaid program and any rules and regulations promulgated thereunder, as such standards, requirements. rules and regulations may be amended from time to time. Additionally, Provider warrants that it will comply with the National Labor Department Regulations regarding employee notification requirements for federal contractors and subcontractors as set forth in 29 CFR Part 471. Appendix A to Subpart A. G. 23 Compliance with Federal and State False Claims Acts and Regulations. Provider acknowledges that, with regard to certain State and Federal health care programs, the federal False Claims Act and similar state laws (collectively, the "FCA") prohibit billing for services or goods not provided, billing for undocumented services, billing for services that are medically unnecessary, participating in unlawful kickbacks and rebates, and other inappropriate or wasteful conduct. Provider understands that a violation of the FCA may result in financial penalties, exclusion from the Medicaid program. and imprisonment. If Provider has not implemented its own policies and procedures regarding FCA compliance pursuant to the Deficit Reduction Act of 2005 (the "DRA"), and if this Agreement includes a Benefit Program subject to the requirements of the DRA, Provider agrees to make a copy of Colorado Access' Deficit Reduction Act policies available upon request from Colorado Access to Provider's officers, employees, and agents who will assist with Provider's rendering of health items or services, or billing or coding functions. G. 24 Physician Self -Referral and Anti -Kickback Compliance. Provider represents that Provider and its Provider Representatives have not entered into, and during the term of this Agreement agree not to enter into, any financial relationships prohibited under the Federal Physician Self -Referral law (42 U.S.C. § 1395nn), associated implementing regulations, and similar State statutes and regulations. Provider further represents that Provider and its Provider Representatives have not engaged in, and during the term of this Agreement, will not to engage in any activities prohibited under the federal Anti -Kickback statutes (42 U.S.C. §§ 1320a-7, 1320a -7a, and 1320a -7b), associated implementing regulations, and similar State statutes and regulations. G. 25 State Approval. Provider acknowledges and agrees that if at any time Provider provides PCMP services under this Agreement to ten percent (10%) or more of the RCCO Members assigned to Colorado Access, the approval of Provider to provide such services is required by HCPF. RCCO Professional Provider Agreement Revised May 2011 Page 12 of 15 [Signature Page Follows] RCCO Professional Provider Agreement Revised May 2011 Page 13 of 15 This Agreement shall become effective as of the date indicated in the first sentence of this Agreement and shall not be considered executed until both parties have affixed their signatures below. WELD COUNTY GOVERNMENT DBA WELD COUNTY DEPARTMENT OF PUBLIC HEALTH ArNll, ENVIRONMENT Wij„llam F. Garcia Printed Name Chair, Board of County Commissioners Title FEB 2 5 7013 Date RCCO Professional Provider Agreement Revised May 2011 COLORADO _ ACCESS i9je Signatur Phil Reed Printed Name Chief Financial Officer Title 3-7-13 Date Page 14 of 15 020/3-61/79 ATTACHMENT A PCMP AGREEMENT WITH HCPF Affixed Hereto in Full RCCO Professional Provider Agreement Revised May 2011 Page 15of15 CLERK TO THE BOARD PHONE: (970) 336-7215, Ext. 4226 FAX: (970) 352-0242 1150 O STREET P. O. BOX 758 GREELEY, COLORADO 80632 Colorado Access Attn: Director Provider Network Services PO Box 17580 10065 East Harvard Avenue #600 Denver, Colorado 80217-0580 June 25, 2013 RE: Unsigned Document (HCPF) To Whom it May Concern: On the 25th day of February, 2013, the Board of Weld County Commissioners approved a Professional Provider Agreement for the Accountable Care Collaborative Program. As of today we still have not received a fully executed Contract back from your department. Could you please check your files and see if it has been signed, and return an original to the Weld County Department of Public Health and Environment, or let them know when they can expect a fully executed document from you. If you wish to see the document, let me or the Health Department know, and we can e-mail you a pdf of it. If you have questions or need additional information, please do not hesitate to contact me at (970) 336-7215, Extension 4227. Very truly yours, Donna Bechler Deputy Clerk to the Board dbechler@co.weld.co.us Hello