HomeMy WebLinkAbout20111210.tiff RESOLUTION
RE: APPROVE TASK ORDER CONTRACT FOR WOMEN'S WELLNESS CONNECTION
PROGRAM AND AUTHORIZE CHAIR TO SIGN
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, the Board has been presented with a Task Order Contract for the Women's
Wellness Connection 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 Department of Public Health and Environment,
commencing June 30, 2011, and ending June 29, 2012,with further terms and conditions being as
stated in said contract, and
WHEREAS, after review, the Board deems it advisable to approve said contract, 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 Task Order Contract for the Women's Wellness Connection 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 Department of Public Health and Environment be, and hereby is,
approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said contract.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 16th day of May, A.D., 2011.
BOARD OF COUNTY COMMISSIONERS
WELD !/aUNTY, C RADO
ATTEST:
' ar•ara Kirkmeyer, Chair
Weld County Clerk to the •. %0.� ` c----
/�, `, ,(, ' t I_ , _ , . - Sean P. way, Pro-Tem -\
Deputy Clerk to the Bgar�
Will' F. Garcia r
AP S ORM: O- ate.{ t- c
David E. Long /
County Attorney c(9-3 �Qywl, m�
D uglas)Rademach r
Date of signature: aid_ llI
II Or ID 10, ( . \AL 2011-1210
LkJ-11/44-Al U - 9..1 - 1 I HL0038
6 6 1 2 0 1 1 Memorandum
.� TO: Barbara Kirkmeyer, Chair
Board of County Commissioners
W E L D___ C 0 U N T Y FROM: Mark E. Wallace, MD, MPH, Director
Department of Public Health and
Environment
DATE: 5-3-11
SUBJECT: Women's Wellness Connection Task Order
Contract
Enclosed for Board review and approval is Task Order Contract between the Colorado
Department of Public Health and Environment and Weld County Board of County
Commissioners on behalf of the Department of Public Health and Environment(WCDPHE).
This contract is for continuation of the Women's Wellness Connection (WWC) program.
If approved, the funding for this contract will allow the Department to provide low-income,
uninsured and underserved women demonstrating lawful presence in Colorado access to timely,
high quality screening and diagnostic services to detect breast and/or cervical cancer at the
earliest stages. Weld County will be reimbursed by the State according to current Medicare rates
for the provision of these services.
The term of this Contract is June 30, 2011 through June 29, 2012. Funding for this contract
period will not exceed $17,500.00. Of this amount$8,750.00 is provided by the State of
Colorado funding source and federal funding dollars in the amount of$8,750.00. I recommend
your approval of this task order contract.
Enclosures
2011-1210
STATE OF COLORADO
John W.Hickenlooper,Governor -
Christopher E. Urbina,MD, MPH , bv coCo:
Executive Director and Chief Medical Officer m
Dedicated to protecting and improving the health and environment of the people of Colorado
4300 Cherry Creek Dr.S. Laboratory Services Division •is�b
Denver,Colorado 80246-1530 8100 Lowry Blvd.
Phone(303)692-2000 Denver,Colorado 80230-6928 Colorado Department
Located in Glendale,Colorado (303)692-3090 of Public ItIth
http://www.cdphe.state.co.us and Environment
•
June 14, 2011
Mark Wallace
Weld County Department of Public Health and Environment
1555 North 17th Avenue
Greeley, CO 80631
Dear Mr. Wallace,
Enclosed is your copy of the fully executed Colorado Department of Public Health and Environment(CDPHE)
Contract Amendment listed below. You may begin work on June 30,2011.
Contractor Name: Weld County Department of Public Health and Environment
Original Contract: 11 FLA 30039
Division: Prevention Services Division —PSD
Program Name: Women's Wellness Connection
Project Name: Service Delivery
Reason for Contract: New Contract
Please note: The CDPHE Contract Routing Number of your contract has changed from when your contract was
signed. This change does not affect the performance of the contract or any of its terms and conditions. The change
is in the fiscal year, now 11 instead of 12, that precedes the CDPHE Division identifier, FLA.
Please contact me with any questions or concerns. My contact information is listed below.
Sincerely,
i�. •
Daniel Huse,JD
Contracts Coordinator
Colorado Department of Public Health and Environment
303-691-4942
daniel.huse@state.co.us
DEPARTMENT OF PUBLIC IIFAIJH AND ENVIRONMENT
ROUTING NO,11 FLA 30039
APPROVED TASK ORDER CONTRACT-WAIVER#154
This Task Order Contract is issued pursuant to Master Contract made on 01/23/2007,with routing number 08 FAA 00052
STATE: CONTRACTOR
State of Colorado for the use&benefit of the Board of County Commissioners of Weld County
Department of Public Health and (a political subdivision of the State of Colorado)
Environment 915 10'I'Street
PSD—WWC Greeley,Colorado 80632-0758
4300 Cherry Creek Drive South for the use and benefit of the
Weld County Department of Public Health and
Denver,Colorado 80246-1523
Environment
1555 North 17th Avenue
Greeley,Colorado 80631
TASK ORDER MADE DATE: CONTRACTOR ENTITY TYPE:
04/01/2011 Colorado Political Subdivision
PO/SC ENCUMBRANCE NUMBER:
PO FLA PPG1130039
TERM: BILLING STATEMENTS RECEIVED:
This Task Order shall be effective upon Monthly
approval by the State Controller,or designee,
or on 06/30/2011,whichever is later. The SIATCTORYAUIItORIIT
Task Order shall end on 06/29/2012. Not Applicable
PRICE STRUCTURE_ CONTRACT PRICE NOT TO EXCEED.
Cost Reimbursement $17,500.00
PROCUREMENT METIIOD: FEDERAL FUNDING DOLLARS: $8,750.00
Exempt STATE FUNDING DOLI.ARS: $8,750.00
BID/RIP/LIST PRICE AGREEMENT NUMBER: MAXIMUM AMOUNT AVAILABLE PER FISCAL YEAR:
Not Applicable FY 12: $17,500.00
LAB SPECIFIED VENDOR SIAICTl:
Not Applicable
SIA i;REPRESENTATIVE: CONTRACTOR REPRbSEN IATIVL
Kathy Jacobsen Mark Wallace
Department of Public I Iealth and Weld County Department of Public Health
Environment and Environment
PSD—WWC 1555 North 17th Avenue
4300 Cherry Creek Drive South Greeley,CO 80631
Denver,CO 80246-1523
SCOPE OP AFORK
Perform work for the Women's Wellness Connection (WWC) Program to conduct breast and cervical
cancer screenings of program eligible women.
Page 1 of 6 Rev 6/25/09
i
Ex11IBI1S:
The following exhibits are hereby incorporated:
Exhibit A- Additional Provisions (and its attachments if any—e.g.,A-1,A-2,etc.)
Exhibit B - Statement of Work (and its attachments if any—e.g.,B-1, B-2,etc.)
GENERAL PROVISIONS
The following clauses apply to this Task Order Contract. These general clauses may have been expanded upon or made
more specific in some instances in exhibits to this Task Order Contract. To the extent that other provisions of this Task
Order Contract provide mote specificity than these general clauses,the more specific provision shall control.
This Task Order Contract is being entered into pursuant to the terms and conditions of the Master Contract
including,but not limited to, Exhibit One thereto. The total term of this Task Order Contract, including
any renewals or extensions, may not exceed five(5)years. The parties intend and agree that all work shall
be performed according to the standards,terms and conditions set forth in the Master Contract.
2. In accordance with section 24-30-202(1),C.R.S.,as amended,this Task Order Contract is not valid until it
has been approved by the State Controller,or an authorized delegee thereof. The Contractor is not
authorized to,and shall not;commence performance under this Task Order Contract until this Task Order
Contract has been approved by the State Controller or delegec. The State shall have no financial obligation
to the Contractor whatsoever for any work or services or,any costs or expenses,incurred by the Contractor
prior to the effective date of this Task Order Contract. If the State Controller approves this Task Order
Contract on or before its proposed effective date,then the Contractor shall commence performance under
this Task Order Contract on the proposed effective date. If the State Controller approves this Task Order
Contract after its proposed effective date,then the Contractor shall only commence performance under this
Task Order Contract on that later date. The initial term of this Task Order Contract shall continue through
and including the date specified on page one of this Task Order Contract, unless sooner terminated by the
parties pursuant to the terms and conditions of this Task Order Contract and/or the Master Contract.
Contractor's commencement of performance under this Task Order Contract shall be deemed acceptance of
the terms and conditions of this Task Order Contract.
3. The Master Contract and its exhibits and/or attachments are incorporated herein by this reference and made
a part hereof as if fully set forth herein. Unless otherwise stated,all exhibits and/or attachments to this Task
Order Contract are incorporated herein and made a part of this Task Order Contract. Unless otherwise stated,
the terms of this Task Order Contract shall control over any conflicting terms in any of its exhibits. In the event
of conflicts or inconsistencies between the Master Contract and this Task Order Contract(including its exhibits
and/or attachments),or between this Task Order Contract and its exhibits and/or attachments,such conflicts or
inconsistencies shall be resolved by reference to the documents in the following order of priority: I)the
Page 2 of 6 Rev 6/25/09
Special Provisions of the Master Contract;2)the Master Contract(other than the Special Provisions)and its
exhibits and attachments in the order specified in the Master Contract;3)this Task Order Contract;4)the
Additional Provisions- Exhibit A,and its attachments if included,to this Task Order Contract; 5) the
Scope/Statement of Work- Exhibit B,and its attachments if included,to this Task Order Contract;6)other
exhibits/attachments to this Task Order Contract in their order of appearance.
4. The Contractor, in accordance with the terms and conditions of the Master Contract and this Task Order
Contract,shall perform and complete, in a timely and satisfactory manner,all work items described in the
Statement of Work and Budget,which are incorporated herein by this reference,made a part hereof and
attached hereto as"Exhibit B".
5. The State, with the concurrence of the Contractor, may,among other things,prospectively renew or extend
the term of this Task Order Contract, subject to the limitations set forth in the Master Contract,increase or
decrease the amount payable under this Task Order Contract,or add to,delete from,and/or modify this
Task Order Contract's Statement of Work through a contract amendment. To be effective,the amendment
must be signed by the State and the Contractor, and be approved by the State Controller or an authorized
delegate thereof. This contract is subject to such modifications as may be required by changes in Federal
or State law,or their implementing regulations. Any such required modification shall automatically be
incorporated into and be part of this Task Order Contract on the effective date of such change as if fully set
forth herein.
6. The conditions,provisions,and terms of any RFP attached hereto,if applicable, establish the minimum
standards of performance that the Contractor must meet under this Task Order Contract. If the Contractor's
Proposal, if attached hereto,or any attachments or exhibits thereto,or the Scope/Statement of Work -
Exhibit B,establishes or creates standards of performance greater than those set forth in the RFP,then the
Contractor shall also meet those standards of performance under this Task Order Contract.
7. STATEWIDE CONTRACT MANAGEMENT SYSTEM[This section shall apply when the Effective
Date is on or after July 1, 2009 and the maximum amount payable to Contractor hereunder is S100,000 or
higher!
By entering into this Task Order Contract,Contractor agrees to be governed,and to abide,by the
provisions of CRS §24-102-205,§24-102-206, §24-103-601, §24-103.5-101 and §24-105-102 concerning
the monitoring of vendor performance on state contracts and inclusion of contract performance information
in a statewide contract management system.
Contractor's performance shall be evaluated in accordance with the terms and conditions of this Task Order
Contract,State law, including CRS §24-103.5-101,and State Fiscal Rules,Policies and Guidance.
Evaluation of Contractor's performance shall be part of the normal contract administration process and
Contractor's performance will be systematically recorded in the statewide Contract Management System.
Areas of review shall include, but shall not be limited to quality,cost and timeliness.Collection of
information relevant to the performance of Contractor's obligations under this Task Order Contract shall be
determined by the specific requirements of such obligations and shall include factors tailored to match the
requirements of the Statement of Project of this Task Order Contract.Such performance information shall
be entered into the statewide Contract Management System at intervals established in the Statement of
Project and a final review and rating shall be rendered within 30 days of the end of the Task Order Contract
term.Contractor shall be notified following each performance and shall address or correct any identified
problem in a timely manner and maintain work progress.
Should the final performance evaluation determine that Contractor demonstrated a gross failure to meet the
performance measures established under the Statement of Project,the Executive Director of the Colorado
Department of Personnel and Administration(Executive Director),upon request by the Colorado
Department of Public Health and Environment and showing of good cause, may debar Contractor and
Page 3 of 6 Rev 6/25/09
prohibit Contractor from bidding on future contracts.Contractor may contest the final evaluation and result
by: (i) filing rebuttal statements,which may result in either removal or correction of the evaluation(CRS
§24-105-102(6)),or(ii) under CRS §24-105-102(6),exercising the debarment protest and appeal rights
provided in CRS §§24-109-106, 107,201 or 202,which may result in the reversal of the debarment and
reinstatement of Contractor,by the Executive Director, upon showing of good cause.
8. If this Contract involves federal funds or compliance is otherwise federally mandated,the Contractor and
its agent(s) shall at all times during the term of this contract strictly adhere to all applicable federal laws,
state laws,Executive Orders and implementing regulations as they currently exist and may hereafter be
amended. Without limitation,these federal laws and regulations include the Federal Funding
Accountability and Transparency Act of 2006(Public Law 109-282),as amended by §6062 of Public Law
110-252,including without limitation all data reporting requirements required there under. This Act is also
referred to as FFATA.
Page 4 of 6 Rev 6/25/09
THE PARTIES HERETO I1AVE EXECUTED THIS CONTRACT
* Persons signing for Contractor hereby swear and affirm that they are authorized to act on Contractor's
behalf and acknowledge that the State is relying on their representations to that effect.
CONTRACTOR: STATE OF COLORADO:
BOARD OF COUNTY COMMISSIONERS John W. Hickenlooper, GOVERNOR
OF WELD COUNTY
(A political subdivision of the State of Colorado)
For the use and benefit of the
WELD COUNTY DEPARTMENT OF
PUBLIC HEALTH AND ENVIRONMENT
Weld County, Colorado
Legal Name of Contracting Entity
ekte-y,eyt-,
For Executive Director
DD ltd} Department of Public Ilealth and Environment
Signature ofAuth zed OfficerMAY 16 2011
Barbara Kirkmeyer
Print Name of Authorized Officer
Department rogram Approval:
Chair By
Print Title of Authorized Officer
•
ALL CONTRACTS MUST BE APPROVED BY THE STATE CONTROLLER
CRS§24-30-202 requires the State Controller to approve all State Contracts.This Contract is not valid until
signed and dated below by the State Controller or delegate.Contractor is not authorized to begin performance until
such time.If Contractor begins performing prior thereto,the State of Colorado is not obligated to pay Contractor
for such performance or for any goods and/or services provided hereunder.
STATE CONTROLLER:
David J.McDermott,CPA
W () COU"ITY DEPARTMENT OF
'h I r . T; AND ENVIRONMENT
By, )\000.45;t ° Q CIS
y E. Wallace, MD, MPH-Director
Date
Page 5 of 6 Rev 6/25/09
x;47/-/2/K
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Page 6 of 6 Rev 6/25/09
Exhibit A
ADDITIONAL PROVISIONS
To Task Order Contract Dated 04/01/2011 -Contract Routing Number 11 FLA 30039
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified
above.
1. Termination of Contract.Execution of this contract shall constitute an effective termination of the
CDPHE Contract,Original Contract Routing Number 09 FLA 01030, including all amendments,
modifications and grant funding change letters incorporated into the Original Contract,The termination
date of the Original Contract,Contract Routing Number 09 FLA 01030,shall be on the effective date of
this contract.The Survival of Certain Terms clause will allow for invoicing of services rendered under the
Original Contract
2. The list of acronyms attached hereto as Attachment A-1 may be referenced to in Exhibit A,Exhibit B,
and all and any attachments thereof in this Task Order Contract.
3. This Task Order Contract contains federal and state funds(see Catalog of Federal Domestic Assistance
(CFDA)number 93.283)
4. The United State Department of Health and Human Services("USDHHS"),through the Centers for
Disease Control and Prevention("CDC")has awarded federal funds under Award number
5U5SDP000848-05,hereinafter"Award",to perform the following—breast and cervical cancer screenings,
and diagnostic services,if needed,to the point of definitive diagnosis.
If the underlying Award authorizes the State to pay all allowable and allocable expenses of a contractor as
of the effective date of that Award,then the State shall reimburse the Contractor for any allowable and
allocable expenses of the Contractor that have been incurred by the Contractor since the proposed effective
date of this Task Order Contract. If the underlying Award does not authorize the State to pay all allowable
and allocable expenses of a contractor as of the effective date of that Award,then the State shall only
reimburse the Contractor for those allowable and allocable expenses of the Contractor that are incurred by
the Contractor on or after the effective date of this Task Order Contract,with such effective date being the
later of the date specified in this Task Order Contract or the date the Task Order Contract is signed by the
State Controller or delegee.
5. Notwithstanding the terms contained in General Provisions of the Master Contract,Section 27,Annual
Audit,for the purpose of this Task Order,the Contractor is a Vendor as defined by Office of Management
and Budget(OMB)Circular A-133 (Audits of States,Local Governments,and Non-Profit Organizations).
6. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 25,
Conformance with Law,Contractor shall comply with all applicable requirements of the following for
Contractor's respective entity type:
a. 2 Code of Federal Regulations(CFR)Part 215, Uniform Administration Requirements for Grants
and Agreements with Institutions of Higher Education, Hospitals, and Other Non-Profit
Organizations,formerly known as OMB Circular A-110;
b. OMB Circular A-102,Grants and Cooperative Agreements with State and Local Governments;
c. 2 C.F.R.230,Cost Principles for Nonprofit Organizations,formerly known as OMB Circular A-
122;
d. 2 C.F.R. 225,Cost Principles for State. Local, and Indian Tribal Governments,formerly known as
OMB Circular A-87;
e. 2 C.F.R.220,Cost Principles for Educational Institutions,formerly known as OMB Circular A-
21;
OMB Circular A-133,Audits of States, Local Governments, and Non-profit Organizations
To be attached to CDPHE Revised: 12/19/06
Task Order v1.0(11/05)contract template
Page 1 of 3
Exhibit A
7. To receive compensation under this Task Order Contract,the Contractor shall provide breast and cervical
cancer screening services to women during the term of this Task Order Contract.The Contractor shall also
provide Women's Wellness Connection approved diagnostic services to women that meet the criteria in
accordance with the Statement of Work attached hereto as Exhibit B and incorporated herein. The
Contractor shall be paid in accordance with rates as outlined in this Task Order Contract.
To be considered for payment,billing for payments pursuant to this Task Order Contract must be received
within a reasonable time after the period for which payment is requested; but in no event no later than sixty
(60)calendar days after the relevant performance period has passed.Final billings under this Task Order
Contract must be received by the State within a reasonable time after the expiration or termination of this
Task Order Contract; but in no event no later than sixty(60)calendar days from the effective expiration or
termination date of this Task Order Contract.
8. Time Limit For Acceptance Of Deliverables.
a. Evaluation Period. The State shall have thirty(30)calendar days from the date a deliverable is
delivered to the State by the Contractor to evaluate that deliverable,except for those deliverables
that have a different time negotiated by the State and the Contractor.
b. Notice of Defect. If the State believes in good faith that a deliverable fails to meet the design
specifications for that particular deliverable,or is otherwise deficient,then the State shall notify
the Contractor of the failure or deficiencies,in writing,within thirty(30)calendar days of: 1)the
date the deliverable is delivered to the State by the Contractor if the State is aware of the failure or
deficiency at the time of delivery;or 2)the date the State becomes aware of the failure or
deficiency. The above time frame shall apply to all deliverables except for those deliverables that
have a different time negotiated by the State and the Contractor in writing pursuant to the State's
fiscal rules.
c. Time to Correct Defect. Upon receipt of timely written notice of an objection to a completed
deliverable,the Contractor shall have a reasonable period of time,not to exceed ten(10)calendar
days,to correct the noted deficiencies. If the Contractor fails to correct such deficiencies within
ten(10)calendar days,the Contractor shall be in default of its obligations under this Task Order
Contract and the State,at its option,may elect to terminate this Task Order Contract or the Master
Contract and all Task Order Contracts entered into pursuant to the Master Contract.
9. Health Insurance Portability and Accountability Act(HIPAA)Business Associate Determination.
The State has determined that this Task Order Contract does not constitute a Business Associate
relationship under HIPAA.
10. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 9,Rights in
Data, Documents and Computer Software or Other Intellectual Property,unless otherwise provided for,all
data collected or produced or derived exclusively from the Contractor's or subcontractor's work under this
Task Order Contract shall remain the sole property of the State,whether in individual,aggregate, identified
or de-identified form or any other form required by the State. To facilitate follow-up,research,surveillance
and evaluation,any such data collected,used or acquired shall be made available in any form required by
the State,to the State and any other entity designated by the State.
Any such data collected,used or acquired shall be used solely for the purposes of this Task Order Contract.
The Contractor and its subcontractors agree not to release,divulge,publish,transfer,sell,or otherwise
make known any such data to unauthorized persons without the express prior written consent of the State or
as otherwise required by law.This includes a prior written request by the Contractor to the State for
submission of abstracts or reports to conferences,which utilize data collected under this Task Order
Contract.
To be attached to CDPHE Revised: 12/19/06
Task Order v1.0(11/05)contract template
Page 2 of 3
Exhibit A
Notwithstanding the foregoing,the Contractor shall be entitled to retain a set of any such data collected or
work papers necessary to perform its duties under this Task Order Contract and in accordance with
professional standards.
11. Notwithstanding the terms contained in General Provisions of the Master Contract, Section 9,Rights in
Data, Documents and Computer Software or Other Intellectual Property,or Section 23.i,General
Provisions, Media or Public Announcements,the State of Colorado, specifically the Department of Public
Health and Environment, shall be the owner of all printed materials,graphic representations,educational
materials,audio-visual products,or any other media,in whatever form,created under this Task Order
Contract.This requirement applies,but is not limited to,any brochure, flyer, presentation,billboard,radio
spot, website,banner advertisement. The State reserves the right to require logos, or other wording on any
material,representation, product or other media form created under this Task Order Contract.
Any material,representation,product or other media form that will use the State's or logo or information
must be approved by the State prior to production and distribution. A minimum of ten(10)business days is
required for the review and approval process.
12. Notwithstanding the terms contained in the General Provisions of the Master Contract,Section 25,
Conformance with Law,the Contractor shall comply with the provisions of Section 601 of Title VI of the
Civil Rights Act of 1964, as amended,which states that"no person in the United States shall on the
grounds of race,color or national origin,be excluded from participation in,be denied the benefits of,or be
subjected to discrimination under any program actively receiving Federal financial assistance." The Office
for Civil Rights has established that it is the responsibility of any program that is a recipient of federal
funds to ensure that any Limited English Proficient(LEP)person or beneficiary have meaningful access to
programs, services and information. The Contractor and contract personnel shall adopt and implement
policies and procedures in which reasonable steps are taken to provide language assistance in order to
ensure equal access to LEP persons or beneficiaries. The Contractor and contract personnel shall advise
LEP individuals that language assistance will be provided at no cost to the LEP person or beneficiary.
13. The Contractor affirms that it maintains no affiliations or contractual relationships,direct or indirect,with
tobacco companies,owners, affiliate,subsidiaries, holding companies or companies involved in any way in
the production,processing,distribution,promotion, sales,or use of tobacco.
14. The State may increase or decrease funds available under this Task Order Contract using a Grant Funding
Letter substantially equivalent to Attachment A-2.The Grant Funding Change Letter is not valid until it
has been approved by the State Controller or designee.
15. Notwithstanding anything in this Task Order to the contrary,the parties understand and agree that all terms
and conditions of this Task Order which may require continued performance,compliance,or effect beyond
the termination date of this Task Order and shall survive such termination date and shall be enforceable by
the State as provided herein in the event of failure to perform or comply by the Contractor.
16. The State of Colorado,specifically the Colorado Department of Public Health and Environment,shall be
the owner of all equipment as defined by Federal Accounting Standards Advisory Board (FASAB)
Generally Accepted Accounting Principles(GAAP) purchased under this Task Order Contract. At the end
of the term of this Task Order Contract,the State shall approve the disposition of all equipment.
17. The Contractor shall not use funds provided under this Task Order Contract for the purpose of lobbying as
defined in Colorado Revised Statutes(C.R. S.)24-6-301(3.5)(a).
To be attached to CDPHE Revised: 12/19/06
Task Order v1.0(11/05)contract template
3 of 3
Attachment A-1
Commonly Used Acronyms And Abbreviations In The Women's Wellness Connection (WWC)
Program That May Be Referenced In The Scope of Work:
ACS American Cancer Society
BCCP Breast&Cervical Cancer Program
Bx Biopsy
CAD Coronary Artery Disease
CBE Clinical Breast Exam
CC Community Coordination
CC Community Coordinator
CCC Colorado Cancer Coalition
CCM Certified Case Manager
CCMC Commission for Case Manager Certification
CDC Centers for Disease Control and Prevention
CDPHE Colorado Department of Public Health and Environment
CFDA Catalog of Federal domestic Assistance
CICP Colorado Indigent Care Program
CM Case Management
CMS Contract Management System
CPT Current Procedural Technology
CTC Connect to Care
DH Denver Health
DHHA Denver Health and Hospital Authority
DI-IHS United States Department of Health and Human Services
ECC Electrocardiogram
EMR Electronic Medical Record
ESL English as a Second Language
FNA Fine Needle Aspiration
FPL Federal Poverty Level
FTP File Transfer Protocol
FTE Full Time Equivalent
GED General Education Development
GYN Gynecological
HIPAA Health Insurance Portability and Accountability Act of 1996
HIT Health Improvement Team
HPV Human Papillomavirus
HR Human Resources
hr Hour
ID Identification
IT Information Technology
MCPN Metro Community Provider Network
MD Medical Doctor
mo Month
MPA Master of Public Administration in Health and Human Services
MPH Master of Public Health
MRI Magnetic Resonance Imaging Scan
MS Master of Science
MOU Memorandum of Understanding
NA Not Applicable
NP Nurse Practitioner
PA Physician's Assistant
PVCHC Peak Vista Community Health Center
PE Presumptive Eligibility
PMR Planning management Region
PN Patent Navigator
Page 1 of 2
Attachment A-1
PO Purchase Order
PSA Public Service Announcement
QI Quarter One
Q2 Quarter Two
Q3 Quarter Three
Q4 Quarter Four
QI Quality Improvement
QOL Quality of Life
RN Registered Nurse
Rx Prescription
SD Service Delivery
UCD University of Colorado Denver
US United States of America
WWC Women's Wellness Connection
yr Year
Page 2 of 2
Attachment A-2
GRANT FUNDING CHANGE LETTER
Date: I State Fiscal Year: I Grant Funding Change Letter# [ CMS Routing # j
TO: Insert Grantee's name
In accordance with Section of the Original Contract routing number , [insert the following
language here if previous amendment(s), renewal(s) have been processed] as amended by [include all
previous amendment(s), renewal(s) and their routing numbers], [insert the following word here if
previous amendment(s). renewal(s) have been processed] between the State of Colorado, Department
of Public Health and Environment and Contractor's Name beginning Insert start date <insert start date of
original contract> and ending on Insert ending date <insert ending date of current contract amendment>,
the undersigned commits the following funds to the Grant:
The amount of grant funds available and specified in Section of <insert contract amendment
number and routing number> is D increased or ❑ decreased by $amount of change to a new total
funds available of$ <insert new cumulative total> for the following reason: . Section
is hereby modified accordingly.
This Grant Funding Change Letter does not constitute an order for services under this Grant.
The effective date of hereof is upon approval of the State Controller or , whichever is later.
STATE OF COLORADO
John W. Hickenlooper, GOVERNOR
Department of Public Health and Environment PROGRAM APPROVAL:
By: Lisa Ellis, Purchasing &Contracts Unit Director By:
Date:
ALL GRANTS REQUIRE APPROVAL BY THE STATE CONTROLLER
CRS§24-30-202 requires the State Controller to approve all State Grants.This Grant is not valid until signed and dated below by
the State Controller or delegate.Grantee is not authorized to begin performance until such time. If Grantee begins performing prior
thereto,the State of Colorado is not obligated to pay Grantee for such performance or for any goods and/or services provided
hereunder.
STATE CONTROLLER
David J. McDermott,CPA
By:
Donald Rieck
Date:
Page 1of1
Effective Date: 1/6/09-Rev 8/25/09
Page 1 of 1
Exhibit B
STATEMENT OF WORK
To Task Order Contract Dated 04/01/2011 —Contract Routing Number 11 FLA 30039
These provisions are to be read and interpreted in conjunction with the provisions of the Task Order Contract specified
above.
•
1. The Contractor, in accordance with the terms and conditions of this Task Order Contract,shall perform and
complete, in a timely and satisfactory manner,all activities described in the approved Scope of Work,
attached hereto as Attachment B-1 and incorporated herein.
•
To be attached to CDPHE Revised: 11/05/10
v 1.0 contract template
Page 1 of 1
Attachment B-1
SCOPE OF WORK
Project Period: June 30, 2011 through June 29, 2012.
Background: The WOMEN'S WELLNESS CONNECTION (WWC) program provides low-
income, uninsured and underserved women demonstrating lawful presence in Colorado access to
timely, high-quality screening and diagnostic services to detect breast and/or cervical cancer at
the earliest stages. It is a state-run program funded by the National Breast and Cervical Cancer
Early Detection Program (NBCCEDP), which is administered through the Centers for Disease
Control and Prevention (CDC), and Amendment 35 Tobacco Tax state funds. Services are
available across Colorado.
Direct Beneficiaries: Direct beneficiaries are women residing in Colorado who are uninsured or
underinsured; and who meet age, income and lawful presence requirements of the program.
Target populations include women of diverse ethnic backgrounds, women living in
geographically isolated and medically underserved areas, those who are rarely or never screened
for breast and/or cervical cancer, and women between the ages of 50-64 for screening
mammograms.
Project Goals:
1. To deliver quality breast and cervical cancer screening and diagnostic services.
2. To provide women with an abnormal screening with quality case management services.
3. To provide these services within performance standards at Medicare rates.
Definitions:
Breast Cancer Screen — Standard testing performed to determine the presence or non-
presence of breast cancer. Standard screening tests include a clinical breast exam (CBE)
and a mammogram.
Cervical Cancer Screen — Standard testing performed to determine the presence or non-
presence of cervical cancer. The standard screening tests are a Pap test and pelvic exam.
Performance Indicators—Measures of clinical quality of care, penetration of screenings
in certain target populations and other health care system benchmarks. Some indicators
are set by the CDC and are linked to WWC federal funding received, and some indicators
are set by the WWC program. Please see Attachment B-1-A for a listing of all
performance standards.
Contractor—Agency responsible for signing and administering this contract.
Definitive Diagnosis—The final point in cancer screening care where it is determined
whether a woman has or does not have breast or cervical cancer. This information is
usually obtained after diagnostic services have been rendered.
Diagnostic Testing — Further testing used when a definitive diagnosis is unable to be
determined by the results of prior screening tests.
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Attachment B-1
eCaST—An electronic database system the WWC Program uses to track women
screened, administer payment to contractors for services performed and for report data to
the CDC.
Network — Any provider site that works under the contractor name and receives fiscal
and administrative assistance to do business.
Subcontractor — An entity in the community that provides services for the Contractor
that the Contractor cannot perform onsite. Agreements are made between the Contractor
and the subcontractor directly; WWC is not involved in these negotiations or agreements.
WWC is not responsible for reporting to or providing reimbursement for any services to
subcontracted entities.
Deliverables: Under this arrangement, the contractor shall provide and perform the following:
1. Administration:
a. Contact information must be updated annually to start work under this contract. An
Agency & Site Contact Form shall be sent to the Contractor by the State; the
Contractor must complete and submit the form by June 30, 2011 in order to start
work under this contract. A sample Agency& Site Contract Form is attached hereto
as Attachment B-1-B, incorporated herein by this reference.
i. All staff changes during the contract year must be reported to the WWC
within fifteen (15) calendar days.
b. Security access to eCaST must be renewed annually to start work under this
contract. An eCaST Renewal Form shall be sent to the Contractor by the State; the
Contractor must complete and submit the form by June 30, 2011 in order to start
work under this contract. A sample eCaST Renewal Form is attached hereto as
Attachment B-1-C, incorporated herein by this reference.
c. The Contractor must maintain a network of subcontractors and submit an updated
list of these subcontractors annually to start work under this contract. A
Subcontractor Form shall be sent to the Contractor by the State; the Contractor must
complete and submit the form by June 30, 2011 in order to start work under this
contract. A sample Subcontractor Form is attached hereto as Attachment B-1-D,
incorporated herein by this reference.
i. All subcontractor changes during the contract year must be reported to the
WWC within fifteen (15) calendar days.
d. The Contractor must identify and support a WWC Coordinator(Attachment B-1-
E).
i The role of the WWC coordinator will be the point of contact between the
Contractor and WWC and will be considered the lead for the program at the
agency level.
ii It is expected that the WWC coordinator will promote and distribute the
communication of updates, policy changes, trainings, conference calls,
Performance Indicator reports, etc. throughout the agency and to necessary
staff.
2 of 9
Attachment B-1
iii It is expected that the WWC coordinator will be responsible for clinical
quality performance at the agency level (as demonstrated in the Performance
Indicator report) and update eCaST data as needed to keep the agency in
compliance.
iv WWC coordinators need to assure that at least one representative from the
agency attends at least 50% of monthly Health Improvement Team (HIT) calls
and 50% of eCaST Users Group calls.
e. The Contractor must identify and support an eCaST Coordinator(Attachment B-1-
E).
i. The role of the eCaST coordinator is to ensure that all information about
women screened under the WWC Program is entered into eCaST.
ii. It is expected that the eCaST coordinator will maintain data in eCaST that is
up-to-date and meets Performance Indicators.
iii. Respond to biannual Minimum Data Element(MDE) clean-up activities
within the deadline specified by WWC.
iv. The WWC Coordinator role and eCaST Coordinator roles may be filled by the
same person at each agency.
f. The Contractor must identify and support a Clinical Liaison (Attachment B-1-E).
i. The clinical liaison must be a nurse or preferably a nurse practitioner,
physician's assistant or physician.
ii. Receive and disseminate information on clinical policy changes and
implementation of clinical guidelines to all clinical staff involved with the
program.
iii. Ensure that program clinical guidelines and policies are understood and
implemented by all clinical staff involved with the program.
iv. Attend 75% of WWC clinical webcasts or review a recorded version at a later
time. Disseminate information shared from webcasts with the Contractor's
clinical staff.
2. Network:
a. Ensure breast and cervical cancer screening services for WWC eligible women are
performed by the Contractor or through a subcontracted network of providers until
a definitive diagnosis has been achieved. Contractors typically subcontract for
services they cannot perform in house such as mammography, breast surgery,
anesthesia etc.
b. Subcontractors:
i Service performed by subcontractors shall:
I. Be performed in an outpatient setting to the extent possible.
2. Not exceed the Medicare reimbursement rate as established in the annual
Current Procedural Technology (CPT) code list, attached hereto as
Attachment B-1-F, incorporated herein by this reference. This list is
updated annually and will be distributed by the WWC Program. The
Contractor is responsible for communicating rate changes to
subcontractors when they occur.
3. Specify that only services on the CPT code list will be performed and
charged to the Contractor.
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Attachment B-1
4. Not be charged to WWC eligible women unless services are performed
that are not on the CPT code list. If services outside of the CPT code list
are required, arrangements for completing and paying for services
should be specified in the subcontractor agreement. Women may be
charged for services outside the CPT code list. but should be notified
before services are performed and be told how much they will cost.
5. Be agreed upon in writing through the use of a signed contract or
memorandum of understanding which includes the Period of service.
3. Enrollment:
The contractor must ensure that women screened under the WWC program:
a. Meet WWC Program Eligibility Requirements, which are attached hereto as
Attachment B-1-G, and incorporated herein by this reference.
i Eligibility guidelines may be updated during the period this scope of work is
in effect. When new eligibility guidelines are adopted for implementation by
the WWC, the Contractor will be notified and responsible for implementing
necessary changes to the Contractor workflow by a date determined by WWC.
ii Provide eligibility screenings and referrals in Spanish or other languages as
requested.
b. Meet Lawful Presence Requirements. This requirement is met for each woman by:
i Annually obtaining a signed lawful presence affidavit, a sample is attached
hereto as Attachment B-1-H, and incorporated herein by this reference and
keeping a copy in the patient's medical record before services are rendered.
ii Annually verifying required documentation for proof of lawful presence
according to Department of Revenue guidelines:
http://www.colorado.gov/cs/Satellite/Revenue-Main/XRM/1216289012112.
iii Document verification of lawful presence on the WWC Patient History Form
(Attachment B-1-N) and in eCaST for each woman the Contractor will be
requesting reimbursement.
1. The"Verified Legal Presence" box must be checked in the electronic
record in eCaST.
2. Failure to document in eCaST will result in non-payment of all services
rendered.
3. If documents used to verify lawful presence expire at any point during
which WWC services were provided, the contractor is responsible for
updating such documents.
4. Billing and Reimbursement:
a. The Contractor shall only request reimbursement from the WWC for a case that
meets eligibility, timeliness, performance and data requirements.
i Cases out of compliance with any of these requirements may be deemed
ineligible for payment by the WWC Program.
b. Reimbursement will be provided at the end of the case when a definitive diagnosis
has been achieved, and all data have been entered correctly into eCaST.
c. Reimbursement is determined by the outcome of the case. The WWC Level
Reimbursement Fee Structure is attached hereto as Attachment B-1-I, and
4 of 9
Attachment B-1
incorporated herein by this reference.
i Cases that exceed sixty (60) days in screening length and negatively affect the
program's Performance Indicators may or may not be reimbursed at the
discretion of the WWC Program.
ii Cases that are closed out in eCaST as "lost to follow-up" or "refused" will be
paid at the highest level achieved.
iii It is expected that if a Contractor starts cancer screening services for a woman,
the same Contractor will be responsible for closing the case and reaching the
point of definitive cancer diagnosis. In cases where more than one WWC
Contractor is involved with the same woman in the same fiscal year, the
WWC program will notify both Contractors involved and request that they
determine a mutually agreeable plan for payment. The WWC program will
only pay one Contractor for services provided. If a mutually agreeable plan
cannot be achieved, the WWC program will make the final determination on
behalf of both Contractors.
iv Rates for the reimbursement process may be revised or updated during the
period this scope of work is in effect. When changes are adopted for
implementation by WWC, the contractor will be notified at least sixty(60)
days prior.
d. It is expected that reimbursement will cover costs associated with:
i Enrollment of women into the WWC Program;
ii Cancer screening services, including Pap test, pelvic exam, clinical breast
exam and mammogram;
iii Case management of abnormal findings;
iv Diagnostic services to the point of a definitive diagnosis, as necessary;
v Entry of all information into eCaST; and
vi Administrative procedures to place women with a positive diagnosis of breast
and/or cervical cancer into the Medicaid Program.
e. Data entered into eCaST are the basis for calculating reimbursement for each
woman screened.
i Data for any WWC procedure must be entered into eCaST within thirty (30)
days of services being performed. Cases entered after this thirty (30) day
period may be deemed ineligible for payment by the WWC program.
ii The contractor shall review eCaST reports #17 - Missing Data, #10—
Procedures not Covered, and #22 - Incomplete Cases Not Yet Paid to identify
women who may have missing essential information prior to the fourteenth
(14th) of each month.
1. It is the responsibility of the Contractor to ensure its network of provider
sites has entered all required data elements prior to the WWC billing
cycle on the fourteenth (14th) of each month.
2. Essential data elements missing from a woman's electronic record may
make the case ineligible for payment.
f. One reimbursement check for all completed screenings that have met data quality
standards and occurred in the prior thirty (30) days will be sent to the Contractor
each month.
i The Contractor will deal with WWC Program staff directly on non-payment
5 of 9
Attachment B-1
of women screened. If WWC staff is unable to rectify reimbursement,the
contractor will work with the WWC fiscal officer to the point of satisfaction
by both parties.
ii Each Contractor receives a capped funding amount that they can use to
provide services under the WWC program each fiscal year. Once this funding
cap has been reached, the WWC program will not pay for any additional
expenses incurred by the Contractor. Contractors are responsible for tracking
expenditures using eCaST Report#81 —Screening Budget Tracking.
5. Service Delivery:
a. The Contractor shall follow and utilize all policies and guidelines according to the
WWC Provider Toolkit located on the internet at:
http://www.cohcalthsource.oru/media/255246/wwc%20toolkit%,2020 I I%20pdf.pdf
i The Provider Toolkit may be updated during the period this scope of work is
in effect. When new documents/policy/guidelines or toolkit directives are
adopted for implementation, the Contractor will be notified and responsible
for implementing necessary changes by a date determined by the WWC.
ii The Contractor shall implement the most current American Society for
Colposcopy and Cervical Pathology (ASCCP) consensus guidelines for
cervical cancer screening services and the California Department of Health
Services Breast Cancer Diagnosis Algorithms for breast cancer screening
services unless otherwise notified by the WWC program.
6. Case Management
a. Case management services are required for every woman with an abnormal
screening in the program. Within the level reimbursement system, Contractors are
reimbursed between $35 and $100 for case management services depending on the
outcome or complexity of the case. Rates for the reimbursement process may be
revised or updated during the period this scope of work is in effect. When changes
are adopted for implementation by WWC, the Contractor will be notified at least
sixty (60) days prior.
b. Case management services are offered through a wide range of intervention types
including but not limited to phone calls, letters, certified letters, clinic visits and
home visits.
c. Case management services may include but are not limited to:
i. Using WWC algorithms to determine next steps
ii. Scheduling diagnostic appointments
iii. Accompanying women to diagnostic appointments
iv. Arranging for qualified interpreter
v. Coordinating clinical care
vi. Explaining abnormal result(s) to patient
vii. Making referrals to other health care services
viii. Providing patient education, advocacy and/or coaching
ix. Working with patient's support system/family
x. Identifying and overcoming barriers to screening or diagnostic services
6 of 9
Attachment B-1
d. Contractors are strongly encouraged to routinely implement several of the above
services including scheduling diagnostic appointments and barrier assessment.
e. As part of the WWC Lost to Follow-up Policy (Attachment B-1-J),Contractors
must make at least three contact attempts, one by certified letter, prior to deeming a
woman lost to follow-up. Data entry of all interventions provided into eCaST is
required for lost to follow-up and refused cases. The timeliness of interventions
provided will be reported on quarterly performance reports.
7. Performance Standards:
a. The contractor will meet or exceed established WWC Performance Indicators
(Attachment B-1-A)
i. Contractors exceeding, meeting or not meeting indicators/reports will be
contacted by the WWC.
1. Contractors not meeting two or more Performance Indicators for a
period of six (6) months or more may be placed under a corrective action
plan.
a. This corrective action plan will have expectations set by the WWC
with time frames for completion.
b. Contractors are responsible for developing and implementing a
quality improvement plan to meet expectations.
c. Unmet expectations may result is cancellation or limitation of the
contract.
8. Site Visits:
a. The WWC may perform site visits to select Contractors as needed. The purpose of
a WWC site visit is to provide, promote and ensure quality breast and cervical
cancer screenings in Colorado at local agencies by focusing on administrative and
management functions and clinical oversight.
b. Selection of contractors to visit is based on, but not limited to,the following:
i. WWC Performance Indicators;
ii. eCaST data reports, specifically Missing Data and Diagnostic Follow up
reports;
iii. Technical assistance needs;
iv. Adherence to this scope of work;
v. Participation in program trainings, conference calls and webinars; and
vi. Ability to refer positively diagnosed women to Medicaid treatment.
c. Site visits will include, but not be limited to:
i. Completion of the WWC prep tool;
ii. Chart audit;
iii. Review of subcontractor agreement(s);
iv. Review of program administration and program management;
v. Review of clinical services and case management activities; and
vi. Implementation of a corrective action plan for agencies not meeting two or
more performance indicators for a period of six (6) months or more prior to
the site visit.
d. WWC will provide a final report to the contractor within thirty (30) days of the
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Attachment B-1
visit.
e. Site Visits evaluations may be used as part of; but will not be a substitute for, the
quarterly Contract Management System (CMS) evaluations (Attachment B-1-M).
9. eCaST System:
a. WWC staff will provide training on the eCaST system to the Contractor, its
administration staff, fiscal staff and provider site staff unless otherwise approved by
the program.
i. Any changes to Contractor staff responsible for WWC data entry must be
reported to the Department within fifteen (15) days.
ii. New data entry staff must be trained by WWC on eCaST within thirty (30)
days of hire, unless otherwise approved by the program.
10. Communication:
a. When corresponding with the WWC, Contractors must use all privacy and security
measures to protect the woman's personal health information.
i. Accepted forms of communication include:
1. WWC identification number used in all email conversations
2. Mail or fax clearly marked "Confidential"
3. HIPAA compliant files transmitted via secure File Transfer Protocol
(FTP) sites.
ii. If a Contractor intends to use data from eCaST for publications, conference
presentations, and/or research projects, the Contractor must notify and receive
prior approval from the WWC Program.
iii. WWC will include the Contractor in all relevant program communications
that may impact the success of this contract, including:
1. Electronic newsletter;
2. eCaST Broadcast messages;
3. Special announcements to WWC providers; and
4. Other communications.
b. Contractor staff will respond to WWC emails, voicemails and faxes within 72 hours
unless otherwise specified.
c. Contractors are encouraged to contact WWC staff at any time with program
questions or needs. A current staff listing with duties assigned can be found in
Attachment B-1-K.
11. Training
a. At least one representative from the Contractor and/or its network provider sites
must attend meetings or conference calls hosted by WWC staff to ensure
compliance with this contract.
i. The Contractor will attend WWC sponsored conference calls, meetings
and trainings, including but not limited to:
1. 50%of WWC monthly Health Improvement Team (HIT) calls;
2. 50%of bimonthly eCaST Users Group Conference Calls;
3. 75% of WWC quarterly clinical webinars; and
4. Other meetings and trainings upon request.
8 of 9
Attachment B-1
ii. WWC will attend conference calls and meetings as needed and upon
special request of the Contractor.
b. Dependent upon federal funding received,the WWC program hopes to host a
conference during the 2012 fiscal year. If funding to support this conference is
received, Contractors will be required to send at least one representative to attend
this conference. Travel and a 1-2 night hotel stay may be required; the program
hopes to offer limited travel scholarships for Contractors that cannot afford this
expense.
12. Medicaid Treatment for WWC Women Diagnosed with Cancer
a. The Contractor will ensure enrollment of eligible women with a positive diagnosis
of breast or cervical cancer into the Breast and Cervical Cancer Medicaid Program
through the following specific procedures:
i. Using of the STEP Enrollment Process, which is attached hereto as
Attachment B-1-L, and incorporated herein by this reference.
ii. Submitting initial completed paperwork to WWC within five (5) business
days of cancer diagnosis. The initial paperwork includes:
• WWC Personal History form
• WWC Rules Form
• Lawful Presence affidavit
• Pathology report confirming the diagnosis
iii. Completing eCaST data entry within twenty-four (24) hours of diagnosis.
iv. Submitting final completed paperwork to WWC within five(5) business days
of receiving approval for presumptive eligibility. This final paperwork
includes:
• Medicaid application signature page
• Presumptive eligible form
v. Submitting complete Medicaid application to local Social Service agencies
within thirty (30) business days after diagnosis.
b. Documents used in the process of enrolling women into Medicaid for treatment
may be updated during the period this scope of work is in effect. When new
documents are adopted for implementation by WWC, the Contractor will be
notified and responsible for implementing necessary changes by a date determined
by the WWC.
9 of 9
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Attachment B-1-B
WOMEN'S WELLNESS
connection
Agency Contacts Form
Agency Number: TBD
Agency Name:
Legal Name:
Phone: Fax:
Physical Address Mailing Address
Agency Contacts
WWC Coordinator Name:
Phone:
Extension:
Fax:
Email:
Clinical Liaison Name:
Phone:
Extension:
Fax:
Email:
eCaST Coordinator Name:
Phone:
Extension:
Fax:
Email:
of 3
Attachment B-1-B
WOMEN'S WELLNESS
connection
Agency Contacts Form
Agency Director Name:
Phone:
Extension:
Fax:
Email:
Contract Administrator Name:
Phone:
Extension:
Fax:
Email:
Signature Authority Name:
Phone:
Extension:
Fax:
Email:
Fiscal Payment Coordinator Name:
Phone:
Extension:
Fax:
Email:
Fiscal Manager Name:
Phone:
Extension:
Fax:
Email:
2 of 3
Attachment B-1-B
'
WOMEN'S WELLNESS
connection
Site Contacts Form
Agency Number: TBD
Agency Name:
Site Number: TBD
Site Name:
Phone: Fax:
Physical Address Mailing Address
Referral Phone: Extension:
Site Contacts
Case Manager Name:
Phone:
Extension:
Fax:
Email:
3 of 3
Attachment 8-1-C
STATE OF COLORADO
John W. Hickenlooper, Governor
Christopher F. Urbina, MD, MPH 6c Coto
Executive Director and Chief Medical Officer :‘`o n, �o
Iti pl
Dedicated to protecting and improving the health and environment of the people of Colorado I* 'I r ,, *I
4300 Cherry Creek Dr. S. Laboratory Services Division .*1876 r�
Denver, Colorado 80246-1530 8100 Lowry Blvd. ----
Phone(303)692-2000 Denver, Colorado 80230-6928 Colorado Department
Located in Glendale, Colorado (303)692-3090 of Public Health
http://www.cdphe.state.co.us slirand Environment
WOMEN'S WELLNESS
connection
I.
WWC/eCaST Coordinator: Fax:
Agency:
Re: Secure External User Id Annual Renewal
From: Dee Thomas, Data Technician Phone: (303) 692-2436
Date:
In accordance with the Colorado Department of Public Health and Environment Policy Manual's
Access Control policy, all authorized state database users are required to periodically renew their
security access forms. The names of the staff at your agency that currently have eCaST access
are listed below. Please have each staff member sign and date where indicated to continue
accessing eCaST. A program manager's signature is also required where indicated. Be advised
that a missing signature on this form will indicate that the employee no longer requires eCaST
access in which case his or her access will be terminated immediately. Please complete and
return this form by 6/30/2011 to the contact shown below. Thank you in advance for your prompt
attention.
Employee Name Employee Signature Date
Program Manager or Supervisor
Print Name Signature Date
Contact: Dee Thomas, fax 303-758-3268.
If you have any questions or comments, please contact Dee at 303-692-2436 or
dolores.thomasstate.co.us, or Christen Lara at 303-692-2531 or christen.laraAstate.co.us.
1 of 1
Attachment B-1-D
WWC Subcontractor Verification — Fiscal year 2011-12
Agency name:
Site 1:
Subcontractor Address City
Site 2:
Subcontractor Address City
Instructions: Above is a list of all subcontractors active for your agency in FY2010-2011.
Check off agencies that you will continue to contract with in FY 2011-2012. Please also
verify the contact information for these subcontractors. Please add any new or missing
subcontractors to the final sheet attached. Contact Christen Lara at
christen.lara@state.co.us or 303-692-2531 if you have questions.
1 of 1
Attachment B-1-E
WOMEN'S WELLNESS
connection
WWC Contacts Descriptions Fiscal Year 2011 -2012
Please read the descriptions below and determine the person or persons who fill each role at
your agency and clinic(s). Please note that agency staff may fill more than one role.
Agency / Administrative Contacts
WWC Coordinator
• One per agency
• Serves as the "point person" for WWC at the agency by overseeing WWC activities and
ensuring that quality and timely patient care are provided
• Serves as the liaison between the WWC state staff and the agency staff
• Is likely to receive any communication from WWC and knows how to disseminate it at
the agency
• Knows all the WWC roles within the agency and who is assigned to each
• Attends monthly Health Improvement Team (HIT) calls
• Is responsible for ensuring that subcontractor contracts are in place
• Is responsible for all communications with subcontractors
• May supervise the case managers
• Must have eCaST access
• Coordinates WWC training for new and existing staff
• May be contacted by ACS Referral Line Call Center staff, WWC Screening Navigators,
or WWC staff when a woman is experiencing breast or cervical cancer symptoms and
she needs an appointment more urgently than through the regular referral line
Clinical Liaison
• One per agency
• Must be a nurse or, preferably, a nurse practitioner, physician's assistant or physician
• Serves as the liaison between the WWC Nurse Consultant and the agency's clinical
staff
• Receives and disseminates information on clinical policy changes, implementation of
clinical guidelines to all clinical staff involved with the program
• Ensures that program clinical guidelines and policies are understood and implemented
by all clinical staff involved with WWC
• Attends WWC clinical webinars and disseminates information shared with agency's
clinical staff
I:\ChandraContracts\In Progress for FY12\WWC\Templates-Masters\SD E 2012 WWC Contacts Descriptions.doc
1 of 3
Attachment B-1-E
WOMEN'S WELLNESS
connection
WWC Contacts Descriptions Fiscal Year 2011 -2012
eCaST Coordinator
• One per agency
• This person is responsible for eCaST activity including quality and timeliness of data
entry
• Responsible for annual renewals
• Assures new users are added to eCaST and receive appropriate eCaST training
• Attends eCaST Users Group meetings
• Determines who responds to data errors
• Must have eCaST access
• Receives and coordinates agency response to the duplicates fax, data error reports and
MDE edit requests from WWC state staff
Agency Director
• One per agency
• This is the highest level person at the agency who is aware of WWC activities and
influences overall program operations
• May receive communication from WWC Program Director and Program Manager
Contract Administrator
• Person(s) responsible for processing of WWC contracts
• Ensures signatures are included and all requested documents are sent to the WWC
contracts management and fiscal teams, as required
• Receives communication from WWC fiscal and contracts management teams
Signature Authority
• Person(s) with the power to sign grant contracts for the agency
Fiscal Payment Coordinator
• One per agency
• Point person for fiscal activity for WWC fiscal activity at the agency
• Receives monthly Grant Activity Statement
• Receives the reimbursement checks from WWC and may be responsible for
reconciliation of payments
• May submit WWC fiscal reports
I:1ChandraContracts\In Progress for FY12\WWC\Templates-Masters\SD E 2012 WWC Contacts Descriptions.doc
2 of 3
Attachment B-1-E
ar
WOMEN'S WELLNESS
connection
WWC Contacts Descriptions Fiscal Year 2011 -2012
• Has access to eCaST (optional but preferred)
Fiscal Manager
• Responsible for overall fiscal operations at the agency
• This is the highest level person at the agency who is aware of WWC fiscal activities and
influences the overall program budget
• May receive communication from WWC Program Director or WWC Fiscal Manager
Site / Clinic Contacts
Case Manager
• At least one per site
• Ensures that women with abnormal screening results, or a diagnosis of cancer, receive
appropriate diagnostic and / or treatment services in a timely manner.
• Has a direct relationship with clients and may provide patient education and/or
communication
• Works closely with clinicians
• Works closely with WWC Nurse Consultant to ensure proper BCCP enrollment
• Must have access to eCaST
I:\ChandraContracts\In Progress for FY12\WWC\Templates-Masters\SD E 2012 WWC Contacts Descriptions.doc
3 of 3
Attachment B-1-F
Medicare Rates and CPT Codes•March 2011
Women's Wellness Connection
Reimbursable Procedures for Fiscal year 06/30/2011 -06/29/2012
Listed below are allowable procedures and the corresponding CPT codes for use in the Women's Wellness Connection program under these general
conditions:
*Screening services should include CBE, pelvic exam,mammogram,and a Pap smear.
Reimbursement for treatment services is not allowed.
Several codes carry technical and professional components.If these components are to billed separately, then bill should be
coded to reflect this status through the inclusion of a modifier(e.g.,77057-TC, 77057-26).
Anesthesia codes should not be charged unless an anethesiologist or nurse anesthetist is in attendance.
*Providers should not be billed under code 99070-supplies and materials not usually provided.These procurdures or items should be billed for with
specific HCPC codes and should only be included if they are not usually provided with the procedure being billed for.
These rates are based on information found on the Centers for Medicare&Medicais Services website,http://www.cros.gov/apps/physician-fee-
schedule/license-agreement.aspx
BOLDED items require WWC pre-approval
2011 CO Tech
CPT code Descripton Prof(26)Rat s (TC)
OFFICE VISITS
Outpatient office visit,detailed history, including clinical breast exam(CBE)and pelvic exam
at 99203 $ 101.63
(if only one service is provided, rate for each is half or$50.82)
d
as
Repeat Clinical Breast Exam(Office Consultation; expanded history,exam, straightforward
g• 99242 decision-making; 30 minutes)Pricing for this code was found on https://catalog.ama- $ 86.38
os assn.org/Catalog/cpt/cpt_search jsp
Surgical consultation(Office Consultation;detailed history, exam, decision-making of low
To• 99243 complexity;40 minutes) Pricing for this code was found on https://catalog.ama- $ 117.94
' assn.org/Catalog/cpUcpt_search.jsp
BREAST SCREENING&DIAGNOSTIC PROCEDURES
76098 Radiological examination, surgical specimen $ 19.16 $ 8.06 $ 11.10
76645 Ultrasound, breast(s), unilateral or bilateral, B-scan and/or real time with image $ 95.85 $ 26.82 $ 69.02
documentation
76942 Ultrasonic guidance for needle placement, imaging supervision and interpretation $ 197.14 $ 33.27 $ 163.87
77031 Stereotactic localization guidance for breast biopsy or needle placement $ 160.33 $ 79.12 $ 81.22
rn 77032 Mammographic guidance for needle placement, breast $ 55.62 $ 27.59 $ 28.03
0 77053 Ductogram,single duct $ 67.62 $ 17.57 $ 50.05
a 77054 Ductogram, multipule duct $ 91.52 $ 22.49 $ 69.02
tt 77055 Mammography, Diagnostic Follow-up, Unilateral $ 86.04 $ 34.63 $ 51.41
77056 Mammography, Diagnostic Follow-up, Bilateral $ 110.02 $ 43.04 $ 66.99
77057 Screening Mammogram, Bilateral (2 view film study of each breast, analog) $ 80.62 $ 34.63 $ 45.99
G0204 Diagnostic Mammogram, Digital $ 166.93 $ 42.70 $ 124.24
G0206 Diagnostic Mammogram, Digital, Unilateral $ 132.11 $ 34.63 $ 97.48
G0202 Screening Mammogram, Bilateral, Digital $ 139.56 $ 34.63 $ 104.93
10021 Fine needle aspiration without imaging guidance $ 140.25
10022 Fine needle aspiration with imaging guidance $ 135.15
19000 Drainage of breast lesion,cyst aspiration $ 107.58
19001 Drainage of breast lesion,each additional cyst, used with 19000 $ 26.05
19100 Breast biopsy,percutaneous, needle core, not using imaging guidance, stereotactic core $ 139.58
biopsy
19101 Breast biopsy, open, incisional, stereotactic core biopsy $ 317.62
19102 Breast biopsy, percutaneous, needle core, using imaging guidance;for placement of $ 210.44
localization clip use 19295
Breast biopsy, percutaneous,stereotactic automated vacuum assisted or rotating biopsy
m• 19103 $ 541.45
device, using imaging guidance
• 19120 Excision/removal of breast lesion $ 457.41
19125 Excision/removal of breast lesion identified by preoperative placement of radiological marker; $ 507.58
open; single lesion
19126 Excision/removal of breast lesion identified by preoperative placement of radiological marker, $ 154.98
open;each additional lesion separately identified by a preoperative radiological marker
19290 Preoperative placement of needle localization wire, breast $ 158.01
19291 Preoperative placement of needle localization wire, breast;each additional lesion $ 67.06
1 of 2
Attachment B-1-F
Tech
CPT code Descripton 2011 ProfProf(26) (TC)
19295 Image guided placement,metallic localization clip, percutaneous,during breast biopsy $ 90.02
88172 Cytopathology,evaluation of fine needle aspirate; immediate cytohistologic study to
codetermine adequacy of specimen(s) $ 50.37 $ 29.79 $ 20.58
—°° 88173 Cytopathology,evaluation of fine needle aspirate, interpretation and report $ 136.92 $ 67.90 $ 69.02
88305 Surgical pathology,gross and microscopic examination $ 105.60 $ 36.24 $ 69.36
co
a 88307 Surgical pathology,gross and microscopic examination; requiring microscopic evaluation of $ 225.35 $ 79.10 $146.26
surgical margins
Anesthesia for procedures on the integumentary system,anterior trunk,not otherwise
N specified.Must be administered by anesthesiologist or nurse anesthetist. Billed for in units,
00400 base rate of 3 units for the procedures always applies(3x$20.58= $61.74)plus time($20.58 $ 20.58
per 15 minute interval,if time goes 1 minute into next 15 minute interval,that counts as 1
unit)
Pre-operative testing;CBC,urinalysis,pregnancy test,etc.These procedures should be
r 99070 medically necessary for the planned surgical procedure. Pre-operative tests should be billed
O for with specific HCPC codes.
CERVICAL SCREENING&DIAGNOSTIC PROCEDURES
88141 Cytopathology(conventional Pap test), cervical or vaginal, any reporting system, requiring $ 28.59
interpretation by physician
Cytopathology(liquid-based Pap test)cervical or vaginal, collected in preservative fluid,
88142 $ 28.51
automated thin layer preparation; manual screening under physician supervision
Cytopathology(conventional Pap test),slides cervical or vaginal reported in Bethesda
88164 $ 14.87
System, manual screening under physician supervision
r 88331 Pathology consultation during surgery, first tissue block,with frozen section(s), single $ 91.08 $ 59.32 $ 31.76
specimen
ro
88332 Pathology consultation during surgery,first tissue block,with frozen section(s),each $ 40.21 $ 29.11 $ 11.10
additional specimen
88305 Surgical pathology,gross and microscopic examination $105.60 $ 36.24 $ 69.36
Papiltomavirus,Human,Amplified Probe(Hybrid Capture II from Digene-HPV Test
87621 (High Risk Typing only)or Cervista HPV HR)(Requires WWC pre-approval unless $ 49.39
provided as a reflex test after an ASCUS or LSIL in menopausal women)
57452 Colposcopy of the cervix,without biopsy $106.91
57454 Colposcopy of the cervix,with biopsy and endocervical curettage $ 151.23
57455 Co poscopy of the cervix,with biopsy $ 140.77
57456 Colposcopy of the cervix,with endocervical curettage $ 133.13
57460 Biopsy of cervix with scope LEEP(WWC pre-approval not required if performed after $287 98
an HSIL Pap test)
57461 Conization of cervix with scope LEEP $ 323.72
57500 Biopsy of cervix, single or multiple,or local excision of lesion,with or without fulgurationo $ 128.89
(separate procedure) Use this code for cervical polyp removal
to 57505 Endocervical curettage(not done as part of a dilation and curettage) $ 100.43
57520 Conization of cervix,with or without fulguration,with or without dilation and curettage, $ 301.71
with or without repair;cold knife or laser
57522 Conization of the cervix or LOOP $260.07
Endometrial sampling(biopsy)with or without endocervical sampling(biopsy),without
58100 cervical dilation,any method(separate procedure) $ 108.10
58110 Endometrial sampling (biopsy)performed in conjunction with colposcopy(No WWC pre- $ 47.53
approval required if performed after an AGUS Pap test)
Supplies and materials(except spectacles),provided by the physician over and above those
99070 usually included with the office visit or other services rendered(list drugs,trays,supplies, or
O materials provided). Supplies and materials should be billed for with specific HCPC codes.
PROCEDURES SPECIFICALLY NOT ALLOWED
Any Treatment of breast cancer,cervical intraepithelial neoplasia and cervical cancer. _
Any HPV testing for screening purposes _
Any Computer Aided Detection (CAD) in breast cancer screening or diagnostics
Any ,Magnetic Resonance Imaging(MRI)in breast cancer screening or diagnostics
2 of 2
Attachment B-1-G
Attachment X— Women's Wellness Connection Eligibility Criteria
To qualify for the Women's Wellness Connection Program, women must:
• Be 40- 64 years of age (mammograms are provided to women 50-64 years of age unless
they are currently experience breast cancer symptoms)
• Be at or below 250% of the Federal Poverty Level
Persons in family 250% of DHHS FEDERAL POVERTY
(Household) GUIDELINES (FPL)
Size Monthly Annual
1 $2,269 $27,225
2 $3,065 $36,775
3 $3,860 $46,325
4 $4,656 $55,875
5 $5,452 $65,425
6 $6,248 $74,975
7 $7,044 $84,525
8 $7,840 $94,075
• Lack health insurance, have health insurance that does not cover screening exams, or
have a high deductible/copay significant enough to delay or refuse screening
• Be lawfully present in the United States. Common forms of ID include:
o Colorado Driver's License
o Colorado ID card
o US Passport
o Permanent Resident Card(1-551)
o Other forms of ID are also acceptable,please see:
http://www.colorado.gov/cs/Satellite/Revenue-Main/XRM/1216289012125
• Have not had a mammogram for 12 months or more unless currently experiencing
symptoms*
• Have not had a Pap test for 12 months (if using conventional Pap smears)or 22 months
(if using liquid based technology) or more unless currently experience symptoms.
Women are eligible for a pelvic exam every year*
• *Breast and cervical cancer screenings may be provided separately if clinically
appropriate
1 of 1
Attachment 8-1-H
(Copy of agency letterhead)
Verification of Lawful Presence
AFFIDAVIT
I, , swear or affirm
under penalty of perjury under the laws of the State of Colorado that(check one):
1 am a United States citizen, or
I am a Permanent Resident of the United States, or
I am lawfully present in the United States pursuant to Federal law.
I understand that this sworn statement is required by law because I have applied for a public benefit. I
understand that state law requires me to provide proof that I am lawfully present in the United States prior
to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent
statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as
perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate
criminal offense each time a public benefit is fraudulently received.
Signature Date
WOMEN'S WELLNESS
1 oft
Attachment B-1-H
(Copy of agency letterhead)
Verification de presencia legal
DECLA RAC ION
Yo, afirmo bajo
juramento y pena de perjurio que de conformidad con las leyes del estado de Colorado (marque
una de las opciones siguientes):
Soy ciudadano(a) de los Estados Unidos, o
Soy residente permanente en los Estados Unidos, o
Mi presencia en los Estados Unidos es legal de conformidad con las leyes federates.
Entiendo que para dar cumplimiento a la ley, esta declaration bajo juramento es necesaria para solicitar la
prestaci6n de un servicio publico. Entiendo que las leyes estatales exigen que compruebe que mi
presencia en los Estados Unidos es legal con el fin de obtener la prestacion de un servicio publico.
Asimismo, reconozco que hacer declaraciones falsas, ficticias o fraudulentas en esta declaration bajo
juramento es un delito de perjurio de segundo grado de conformidad con el cOdigo penal de Colorado y el
Estatuto revisado 18-8-503 del estado y que habra de constituir un delito penal por separado cada vez que
se obtenga la prestaci6n de un servicio publico de manera fraudulenta.
Firma Fecha
WOMEN'S WELLNESS
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vil_
Attachment B-1-J
STATE OF COLORADO
Bill Ritter,Jr.,Governor Martha E. Rudolph,Executive Director /°F c°zo
Dedicated to protecting and improving the health and environment of the people of Colorado fre , �
4300 Cherry Creek Dr.S. Laboratory Services Division
Denver,Colorado 80246-1530 8100 Lowry Blvd. 'rays'
Phone(303)692-2000 Denver,Colorado 80230-6928 TDD Line(303)691-7700 (303)692-3090 Colorado Department
Located in Glendale,Colorado of Public Health
http://www.cdphe.state.co.us and Environment
WOMEN'S WELLNESS
Lost to Follow-up/Refused Service Policy
Effective July 12, 2010
Every attempt should be made to ensure patients have appropriate diagnostic follow-up and/or
treatment required in the Women's Wellness Connection Program. As part of the Center for
Disease Control and Prevention's quality assurance program, all WWC patients should meet the
following criteria:
• 90% or more of W WC patients with an abnormal finding achieve a definitive diagnosis
• 75%or more of WWC patients with an abnormal finding achieve this point of definitive
diagnosis within 60 days or less.
In some cases, patients are likely to be non-compliant with the recommended follow-up after an
abnormal result. The following policies should be used when working with non-compliant
patients. Please note, these processes are only required to follow-up after an abnormal
finding occurs and should only be indicated in eCaST for patients with an abnormal
finding.
Lost to Follow-Up
A patient should be marked as "Lost to Follow-Up" in eCaST when:
I) At least three contact attempts have been completed and documented in the patient's medical
record.
a) This documentation should include the type of contact attempted, date and the outcome.
2) At least one of these contact attempts was a certified letter with a return receipt. A copy of
the certified letter sent and the return receipt should be kept in the patient's medical record.
Lost to Follow-up/Refused Service Policy
Effective July 12,2010
1 of 2
•
Attachment B-1-J
Refused Service
A patient should be marked as "Refused" in eCaST when:
1) The patient verbally refused the follow-up care recommended.
2) The patient refused in writing the follow-up care recommended.
It is recommended that patients are formally notified verbally or in writing of what type of
follow-up is needed, when it is needed and what may happen if the follow-up does not occur.
Documentation of the informed refusal should be kept in the patient's medical record. This can
either be done by quoting the verbal conversation that occurred with the patient or having the
patient sign a form that states specifically what the patient is refusing and that they understand
the risks involved if they do not complete the recommended follow-up.
(These recommendations are from the COPIC Insurance Company guidelines.)
Lost to Follow-up/Refused Service Policy
Effective July I2,2010
2 oft
Attachment B-1-K
COLORADO DEPARTMENT OF
PUBLIC HEALTH & ENVIRONMENT WOMEN'S WELLNESS
Cancer Prevention&Control
Staff Duties
RACHEL FOSTER, Program Manager
MA, BSN, RN 303-692-2511 / Rachel.Foster@state.co.us
• Provide program leadership for Women's Wellness Connection
activities and supervise WWC staff
• Coordinate and manage WWC Advisory Board and Medical
Advisory Committee
• Provide leadership for service delivery activities, quality
assurance/quality improvement initiatives, case management
services, treatment navigation services, and new projects.
• Communicate with CDC, Komen and other funding sources
regarding programmatic activities and grants
JENNIFER WALSH, Nurse Consultant
MS, RN, WHNP 303-692-2323 / Jennifer.Walsh@state.co.us
• Provide instruction and establish Quality Assurance &
Improvement protocols for all provider sites
• Answer requests for clarification and/or approval for additional
diagnostics
• Participate in local, state and national meetings and conference
calls
• Organize clinician training on breast and cervical cancer
guidelines
HEATHER HAGEMAN Public Health Nurse
BSN, RN 303-691-4002 /heatherhageman@state.co.us
• Provide leadership to the Connect to Care program
• Provide leadership to the Clinical Scholars program
• Lead Performance Improvement Plans
• Perform site visits
KRIS MCCRACKEN, Program Coordinator
CAPM 303-692-2599 / Kris.McCracken@state.co.us
• Provide leadership on WWC communication activities
• Provide leadership on WWC provider education activities
• Provide leadership on WWC site visits
• Provide technical assistance to providers
• Provider leadership on special projects
of 2
Attachment B-1-K
CHRISTEN LARA Data Manager
303-692-2531 / Christen.Lara@state.co.us
• Provide leadership on WWC data quality improvement
• Design and implement changes in eCaST
• Analyze and organize clean-up of data submitted in eCaST
• Submit data to Centers for Disease Control twice a year
• Perform monthly billing runs
DEE THOMAS Data Technician
303-692-2436 / Dolores.Thomas@state.co.us
• Provide eCaST training and technical assistance with data entry
and password resets
• Set up new users in eCaST; deactivate access for users no
longer current
• Respond to requests for data
KENT O'CONNOR Program Assistant
303-692-2998 / kent.occonnor@state.co.us
• Provide administrative support and coordination of activities for
Women's Wellness Connection, colorectal and cardiovascular
disease programs
• Directly supports unit director
vacant Community Partnership and Recruitment Coordinator
303-692-2521 /
• Manage Screening Navigator and Community Coordination
contracts
• Evaluate and develop outreach strategies(with focus on
underserved populations)
• Provide programmatic information to community organizations,
government agencies, healthcare providers and agencies,
public/private colleges and universities and resource referral
networks
• Manage Referral Lines: 1-866-951-9355 and 2-1-1 operations
DANIELLE SHOOTS Lead Fiscal Officer
303- 692-2558/ danielle.shoots@state.co.us
DANIEL HUSE Contract Writer
303-692-2524 / Daniethuse@state.co.us
CARLA WOOLFORD Contract Monitor
303-692-2333 / Carla.Woolford@state.co.us
KATHY JACOBSEN Contract Monitor
303-692-2479 / Kathy.Jacobsen@state.co.us
WWC Staff Duties
Updated 3/4/11 -Page 2 of 2
2 of 2
Attachment B-1-L
WOMEN'S WELLNESS
Breast & Cervical Cancer Program (BCCP) Medicaid
Enrollment STEP List
This process should begin within five business days after a breast or cervical
diagnosis occurs. Failure to follow these steps may result in loss of eligibility.
For any questions regarding this process, please call 303-692-2436.
STEP 1 Confirm Eligibility for BCCP & Complete eCaST Data Entry
The provider site must confirm that the woman was eligible for Women's Wellness
Connection and that her diagnosis was made using WWC funds.
Eligibility criteria include:
❑ 40-64 years of age
❑ At or below the 250% Federal Poverty Level
❑ Meets identity and citizenship verification criteria (as stated in the Colorado
Department of Revenue "Rules for Evidence of Lawful Presence" at
http://www.Colorado.qov/cs/Satellite/Revenue-Ma in/X RM/1216289012524)
❑ Does not have health insurance or has health insurance that will not cover
breast or cervical cancer treatment.
STO
The BCCP enrollment process cannot proceed until all data is entered into
eCaST. All information should be completed in eCaST within 24 hours of the
diagnosis.
STEP 2 — Determine Whether the Diagnosis is Eligible for BCCP
The list of eligible diagnoses can be found online at:
http://www.cdphe.state.co.us/PP/cwcci/BCCPEliqibilityChart.pdf
If your pathology report has a diagnosis that is NOT on this list, please call
303-692-2511 before deciding not to proceed.
1 of 4
Attachment B-1-L
STEP 3 — Obtain Approval from WWC
Fax ONLY the following to 303-758-3268.
❑ Personal History Form (must be complete)
❑ WWC Rules Form
❑ Pathology report(s) (Please only send the report that confirms the diagnosis)
❑ Signed lawful presence affidavit.
STOP
Eligibility must be confirmed by WWC staff BEFORE you call the PE Hotline.
A WWC staff person will notify you within three (3) business days of receipt to confirm
eligibility of the woman.
STEP 4 Obtain Presumptive Eligibility (PE) Number in BCCP
STOP;
Do not attempt to get the PE number for the client until you have received
approval from WWC. Clients should not be scheduled for surgery, radiological testing
or treatment until you have received the PE number for the client.
❑ Call the PE Hotline, 303-866-5204, to enroll the client in Presumptive Eligibility
(PE). Please note that the date of eligibility will be the date the definitive
diagnosis was made, not the date of the call to the hotline.
❑ The PE Hotline operator will give you a PE number over the phone. Please note
that PE cards are being replaced with an approval letter mailed by Medicaid to the
client only. The letter will be generated automatically when the Hotline attendant
enters the PE information (usually within 24 hours). The PE number for the client
issued to you by the PE Hotline operator should be documented in the client's
medical chart. This number can be used by the Medicaid provider to check the
Medicaid status of the client.
2 of 4
Attachment B-1-L
STEP 5— Formal Enrollment in—
Medicaid
In order to get treatment benefits under BCCP, you should assist the client in
completing a full Medicaid application available at your local County Human/Social
Services agency, or on the web:
http://www.colorado.gov/cs/Satellite?blobcol=uridata&blobheader=application%2Fpdf
&blobkey=id&blobtable=MungoBlobs&blobwhere=1225954419780&ssbinary=true
(English)
http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf
&blobkey=id&blobtable=MungoBlobs&blobwhere=1228626242862&ssbinarv=true
(Spanish)
Clients should bring proof of income and legal presence.
After you help the client complete this application in your office:
• Please fax copies of the following forms to 303-758-3268 within five (5)
business days of receiving the PE number:
o The signature page of the full application --this is the last page
o The completed PE form
• Please be sure to complete the box in the left lower corner of the
PE form with the information received from the PE Hotline
attendant.
• http://www.cdphe.state.co.us/PP/cwcci/PEForm.pdf (English)
• http://www.cdphe.state.co.us/PP/cwcci/PEFormSpanish.pdf
(Spanish)
• Submit the completed, full application to your County Department of
Human/Social Services office within 30 business days after the diagnosis. For a
listing of these offices, see: http://www.cdhs.state.co.us/servicebycounty.htm
o If you submit the full Medicaid application by fax, please use the "Fax Cover
Sheet for Medicaid Applications." This will alert the staff at your county
Human/Social Service office that this is a BCCP Medicaid application and
facilitate processing. This can be found at:
http://www.cdphe.state.co.us/PP/cwcci/forms/FaxcoversheetforMedicaidApp.pd
f
o Keep a copy of the fax confirmation sheet, the person's name that the
application was sent to and original Medicaid application in the client's chart.
STOP.
:,:.a'.`.. . If this step is not completed correctly, the woman will be dropped from
Medicaid once her PE period is over (usually 45 days).
3 of 4
Attachment B-1-L
STEP 6 Enter the Treatment Start Date in eCaST
Make sure to enter the treatment start date in eCaST as soon as it is available. The
treatment start date is defined as the date that an actual cancer treatment intervention
occurred. Examples include mastectomy, lumpectomy, chemotherapy or radiation
treatment. Surgical consults, patient navigator referrals or breast needle biopsies do
not count as a treatment start date.
4 of 4
Attachment B-1-M
Contract Management System Notification
MEMORANDUM
Effective July 1, 2009, pursuant to C.R.S. §§ 24-102-205, 24-102-206, 24-103.5-101 and 24-
105-102 requiring monitoring of Contractor performance,the Colorado Department of Public
Health and Environment (CDPHE) has adopted the contract management best practice of
evaluating Contractor performance. Evaluations will occur on a quarterly basis throughout the
contract period. An evaluation of the entire contract period will occur when the contract expires.
The evaluation that occurs at the end of the contract period is referred to as the final evaluation.
For those contracts that meet the requirements of C.R.S. §§ 24-102-205, 24-102-206, 24-103.5-
101, and 24-105-102, the final evaluation rating will be posted to the public website maintained
by the Office of the State Controller. This website is a searchable database of all personal
services contracts valued at$100,000 or more entered into after July I, 2009. The following link
provides access to the website http://contractsweb.state.co.us This evaluation process has been
incorporated into the Department's routine contract oversight(or monitoring) practices.
All evaluations will be based on documentation of performance maintained in CDPHE program
and contract files. The following categories will be used to evaluate performance: Quality,
Timeliness, Budget/Price, Business Relations and Deliverables/Requirements specific to each
contract.
The evaluation will result in an overall rating of either"Standard, Above Standard or Below
Standard" for the evaluation period.
A "Standard" rating is defined as satisfactory. CDPHE documentation must demonstrate
consistency in meeting standards, requirements and expectations as defined in the contract.
An "Above Standard" rating is defined as exceeding the standards, requirements and
expectations as defined in the contract. CDPHE documentation must demonstrate consistent and
exceptional performance or superior achievement beyond the requirements of the contract.
A "Below Standard" rating is defined as less than satisfactory. CDPHE documentation must
demonstrate performance does not consistently meet the standards, requirements and
expectations as defined in the contract.
The quarterly and final evaluation form used by CDPHE staff will be emailed to you by your
program contact. The evaluation form will include a list of the documents reviewed.Please note
that the instructions contained in the evaluation form are for Department use. The email will
request a confirmation of receipt of the evaluation within a specific period of time. Your
comments concerning the evaluation results or the Department's performance under the contract
are welcome and encouraged.
If you have questions about the evaluation process, please contact Deb Polk, Contract
Performance Manager for the Colorado Department of Public Health and Environment at 303-
692-2136 or email at deb.polkstate.co.us
Deb Polk, Contract Performance Manager
Colorado Department of Public Health and Environment
1 of 1
Women's Wellness Connection ment8l N ��•
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PATIENT HISTORY FORM WOMEN'S WELLNESS co,,a en,
Connection ofPublicHealrh
(Patients must reapply every year) andEmvonment
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AGENCY# CHART# WWC#
ENROLLMENT/RE-ENROLLMENT DATE ❑ I HAVE VERIFIED THIS PATIENTS LAWFUL PRESENCE DOCUMENTATION IS CURRENT.
J
PATIENT INSTRUCTIONS:Please fill in each part below.Shaded areas need to be filled in completely.
LAST NAME FIRST NAME MIDDLE NAME MAIDEN NAME
LAST 4 NUMBERS OF YOUR SOCIAL SECURITY NUMBER DATE OF BIRTH AGE
Z
0
< WHAT ETHNICITY ARE YOU?CHOOSE ONE BELOW.
V ❑ I am Latina and/or Hispanic. U I am not sure if I am Latina or Hispanic. ❑ I am not Latina or Hispanic.
LL
it
w WHAT RACE(S)ARE YOU?CHECK ALL THAT ARE TRUE.
- ❑Black/African American ❑Asian ❑Pacific Islander
❑White U Alaska Native ❑I am not sure
❑American Indian ❑Aleutian Islander U Other.
❑Latina/Hispanic ❑Native Hawaiian
DO YOU HAVE PRIVATE INSURANCE OR DO YOU HAVE MEDICARE? WOULD YOU LIKE US TO SEND YOU A LETTER
MEDICAID? ❑Yes,part A only. REMINDING YOU OF YOUR SCREENING?
❑Yes,I have Medicaid. ❑Yes,parts A and B. (test phase only)
❑Yes,I have private insurance. ❑No,I do not have Medicare. U Yes
F Check below if any are true. U In English
0 but I have a high deductible. ❑In Spanish
w
U but it does not cover cancer screening. U No,I do not want a letter reminding me of my
U No,I do not have private insurance. screening.
O ❑No,I do not have Medicaid.
CC
Z
w
To the best of my knowledge,the GROSS MONTHLY(before taxes) Number of people living on this income including myself(this may include
income for my household is: people not living in your house):
HOW DID YOU HEAR ABOUT THE WOMEN'S WELLNESS CONNECTION FREE BREAST AND CERVICAL CANCER SCREENING EXAMS?
U Brochure/Poster ❑Hotline(866-951-9355) ❑TV Ad
U Clinic Staff/Physician ❑Newspaper Ad ❑Women's Wellness Connection event or
U Friend/Family Member ❑Patient Navigator staff person
❑Health Fair ❑Radio Ad U Other
PLEASE PROVIDE THE FOLLOWING NUMBERS WE CAN REACH YOU AT: Mailing Address
I—
V Q Home Phone number City State Zip
I—
Z
Z
O Work Phone number County
V
Cell Phone number Email Address
Emergency Contact
List a phone number for someone who could call you if your phone number
changes in the future or in an emergency:
1 of 2
WWC— 4300 Cherry Creek Drive South, AS — Denver, Colorado 80246-1530
Women's Wellness Connection ' / mentB 1 N
FORMULARIO DE ANTECEDENTES DEL PACIENTE WOMEN'S WELLNESS Colorado Depamn
connection ofPubiicHdrh
(Los pacientes deben volver a presenter la solicitud todos los anos) coy c.,:�:,e.a.s, rr. clavira t
AGENCY# CHART# WWC
ENROLLMENT/RE-ENROLLMENT DATE U I HAVE VERIFIED THIS PATIENTS LAWFUL PRESENCE DOCUMENTATION IS CURRENT.
INSTRUCCIONES PARA EL PACIENTE:Complete coda parte a continuation.Las areas sombreadas se deben completer totalmente.
APELLIDO PRIMER NOMBRE SEGUNDO NOMBRE APELLIDO DE SOLTERA
ULTIMOS 4 NUMEROS DE SU NUMERO DE SEGURO SOCIAL FECHA DE NACIMIENTO EDAD
Z
•O
u
v yA QUE ORIGEN ETNICO PERTENECE?ELIJA UNO A CONTINUACION.
❑ Soy latina y/o hispeno. U No estoy seguro de si soy latino o hispana. ❑ No soy latina ni hispana.
u.
I—
w QUE RAZA(S)ES USTED?MARQUE TODO LO QUE SEA VERDADERO.
❑Negro/afroamericana ❑Asiatics U Proveniente de las isles del Pacifico
❑Blanca U Native de Alaska ❑No estoy segura
❑Amerindia U Proveniente de las isles Aleutianas U Otro:
U Lotina/Hispana U Native de Hawai
dTIENE SEGURO MEDICO PRIVADO O TIENE MEDICARE? DESEA QUE LE ENVIEMOS UNA CARTA
MEDICAID? U Si,solo la parte A. PARA RECORDARLE SOBRE SU EXAMEN DE
❑Si,tengo Medicaid. ❑Si,las partes A y B. DETECCION?(solo la fase de prueba)
❑Si,tengo seguro privodo. ❑No,no tengo Medicare. ❑Si
Morgue a continuacian lo que sea verdadero. ❑En ingles
U pero tengo un deducible alto. ❑En espanol
U pero no cubre los examenes de detection U No,no deseo una carte pars recordarme sobre mis
de cancer. examenes de detection.
❑No,no tengo seguro medico privodo.
❑No,no tengo Medicaid.
A mi leal saber y entender,los ingresos BRUTOS MENSUALES(antes de Cantidad de personas que viven con estos ingresos incluida yo(es posible
impuestos)pare mi grupo familiar son: que incluya a personas que no viven en su case):
c'COMOSE ENTERO ACERCA DE LOS EXAMENES GRATUITOS DE DETECCION DE CANCER CERVICOUTERINO Y DE MAMA DE WOMEN'S WELLNESS CONNECTION?
❑Folleto/Poster ❑Linea directs(866-951-9355) U Anuncio de radio
Medico/Personal de le clinics ❑Aviso en un periodico ❑Anuncio televisivo
U Amigo/Familiar U Patient Navigator(programa de asistencia ❑Personal oeventode Women's Wellness Connection
❑Feria de salud pars pacientes) U Otro:
PROPORCIONE LOS SIGUIENTES NUMEROS DONDE PODEMOS Direction postal
O COMUNICARNOS CON USTED:
f
V Numero de telefono de su case particular Ciudad Estado Cbdigo postal
Numero de telefono de su trobajo Condado
O
Numero de telefono celulor Direction de correo electronico
Contacto de emergencia
Incluya un numero de telefono de olguien a quien podamos Ilamor si
cambiara su numero de telefono en el future o en case de emergencia:
2 aft
WWC— 4300 Cherry Creek Drive South, A5 — Denver, Colorado 80246-1530
. 86 . zo Memorandum
TO: Office of Clerk to the Board to the
Weld County Commissioners
W E L D__.-CC OUNTY FROM: Administration Division-Department of
Public Health and Environment
DATE: june aD, aS 01 i
SUBJECT: wW C C OnlY0 c 7-
Attached to this memo is the finalized contract that the Health Department has received.
Please sign and date below indicating you have received the finalized contract and return
this signed memo to the Administration Division of the Health Department.
Please send the confirmation receipt to my attention. Thank you for your assistance with
the processing of this document.
ATTN: Lit to
Contract Name: Womfli s u.je l Iness Con nfc on) Conkact
Resolution Number: c2V 11 - ) a ' O
Finalized Contract Received By: \
Date Received: uk - a\-- II
Enclosure
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