HomeMy WebLinkAbout20110840.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 April 1, 2011, and ending March 31, 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 30th day of March, A.D., 2011.
BOARD OF COUNTY COMMISSIONERS
WE D COUNTY, COLO DO
ATTEST
rbara Kirkmeyer, hair
Weld County Clerk 104:
� :a?d�• (j—
k Y Sean P. y, Pro-Tem �>
Deputy Clerk to the 4t ��
%F. arcia
AP E FORM: EXCUSED
avid E. Long
ounty Attorney Be �b�
kivvictati
Douglasftademache
Date of signature: 9/Z19/8
LI Orin }o Tc ha at- -A°1 I 2011-0840
3- 3O- I I L� �� 0
1861 20 Memorandum
TO: Barbara KCounty Co, Chair
Board of County Commissioners
W E L DEC O U N T Y FROM: Mark E. Wallace, MD, MPH, Director
Department of Public Health au
Environment '
DATE: March 23, 2011
SUBJECT: Women's Wellness Connection/Komen
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 for the Department of Public Health and Environment's Women's Wellness
Connection (WWC) program. Funding for the WWC/Komen task order contract is provided by
private funds of Susan G. Komen in the amount of$21,695.
The scope of work is to provide breast cancer screening services to low-income, uninsured and
underserved women in Colorado in partnership with Well Women's Connection and the Susan
G. Komen for the Cure Denver Metropolitan Affiliate. The task order contract is a supplemental
task order that expands eligibility for women not covered under the state and federally funded
WWC program for the breast cancer screening component. Under the task order, the Weld
County Department of Public Health & Environment will provide clinical breast exams and
referrals for mammography to women not currently eligible for WWC services to enhance access
to timely, high-quality screening and diagnostic services to detect breast cancer at the earliest
stages. Direct beneficiaries are women who are uninsured, meet income requirements of the
program and are not eligible for WWC services.
No additional staff will be added to provide these services as most of the women who will be
eligible for this funding are already being seen in the agency without a payer source for their
breast cancer screening. Funding will not exceed $21,695 for the contract term. The effective
date of this Contract is April], 2011 through March 31, 2012. The State's agreement was March
11, 2011. We have notgdl thetate that we needed additional time to process the task order
contract.
I recommend your``approval ofid$i 'ctlntract.
Enclosure
2011-0840
STATE OF COLORADO
John W. Hickenlooper,Governor
Christopher E. Urbina,MD,MPH ;of co<Op
Executive Director and Chief Medical Officer �� -. __
O
Dedicated to protecting and improving the health and environment of the people of Colorado x k�y� � :
4300 Cherry Creek Dr.S. Laboratory Services Division `*� ,
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 and Environment
April 12, 2011
Judy Nero
Weld County Department of Public Health and Environment
1555 North 17'h Avenue
Greeley, CO 80631
Dear Ms. Nero,
Enclosed is your copy of the fully executed Colorado Department of Public Health and Environment (CDPHE)
Contract Amendment listed below.
Contractor Name: Weld County Department of Public Health and Environment
Contract Number: 11 FLA 29348
Division: Prevention Services Division—PSD
Program Name: Women's Wellness Connection - WWC
Project Name: Komen
Reason for Contract: New Contract
Please contact me with any questions or concerns. My contact information is listed below.
Sincerely,
Daniel Huse, JD
Contracts Coordinator
Colorado Department of Public Health and Environment
303-691-4942
daniel.huse@state.co.us
r
•
DEPARTMENT OF PUBLIC IIEALTM AND ENVIRONMENT
ROUTING NO.11 FLA 29348
APPROVED TASK ORDER CONTRACT-WAIVER#154
This Task Order Contract is issued pursuant to Master Contract made on 0I/23/2007,with routing number 08 FAA 00052
ti IATP] CONTRACTOR:
State of Colorado for the use&benefit of the Board of County Commissioners of Weld County
Department of Public Health and 915 10"Street
Environment Greeley,CO 80632-0758
PSD —WWC For the use and benefit of the
4300 Cherry Creek Drive South Weld County Department of Public Health and
Denver,Colorado 80246 Environment
1555 North 17"I'Avenue
Greeley,CO 80631
TASK ORDER MADE DATE: CONTRACTOR ENTITY TYPE:
03/01/2011 Colorado Political Subdivision
PO/SC I:NC❑MIIRANCE NUMBER
PO FLA PPG1129348
TERM: BILLING STATEMENTS RECEIVED.
This Task Order shall be effective upon Monthly
approval by the State Controller,or designee,
or on 04/01/2011,whichever is later. The SIA IUTORY AUTHORITY
Task Order shall end on 03/31/2012. Not Applicable
TRIO'.S111UCICI(I i'. CONTRACT PRICE MILD)EXCEED:
Cost Reimbursement $ 21,695.00
PROCUREMENT METHOD: FEDERAL FUNDING DOLLARS. $0.00
Exempt STATE FUNDING DOLLARS: 21,695.00
BID/IU'P/LISTI'IRIC:E AGREEMENT NUMBER: MAXIMUMM1OUNT AVAILABLE PEIt FISCAL YEAR
Not Applicable FY 11/12: $21,695.00
LAW SPHCI III I ID VENDOR STATUTE_
Not Applicable
S IATL:I(EPRYSI IN IAH I VF: CC)NTRACIOR REPRESENTATIVE:
Kathy Jacobsen Judy Nero
Department of Public Health and Environment Weld County Department of Public Health and
PSD—W\X'C Environment
4300 Cherry Creek Drive South 1555 17,1
Denver,CO 80246-1523
SCOPE OF WORK.
To provide WWC breast cancer screening services to low-income, uninsured and
underserved women in Colorado through the Susan G. Komen for the Cure Denver
Metropolitan Affiliate.
Page 1 of 6 Rev 6/25/09
�'rl'gO
� r
Lxl I lair$:
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 Budget(and its attachments if any—e.g.,B-1,B-2, etc.)
GENERAL PROVISIONS
The following clauses apply to ties 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 more specificity than these general clauses,the more specific provision shall control.
1. 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 delegee. 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: 1)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 7, 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 HAVE 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 COMMISIONERS OF John W.Hickenlooper, GOVERNOR
WELD COUNTY for the use and benefit of the
WELD COUNTY DEPARTMENT OF
PUBLIC HEALTH AND ENVIRONMENT
(a political subdivision of the State of Colorado)
Weld County, Colorado
Legal Name of Contracting Entity
By
For Executive Director
1('. Uepartment of Public Health and Environment
gnature of Authorized Office MAR s r 2011
Barbara Kirkmeyer
Print Name of Authorized Officer
Department Program Approval:
tmnt�"nV Chair By t(}ike 4,6
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
WELD COUNTY DEPARTMENT OF
B • PUBLIC HEALTH 4ND ENVIRONMENT
/'Date / / 3 L BY: v• kC/6.4C
Mark E. Wallace, MD, MPH-Director
Page 5 of 6 Rev 6/25/09
ani/'--taif0
This page left intentionally blank.
Page 6 of 6 Rev 6/25/09
Exhibit A
ADDITIONAL PROVISIONS
To Task Order Contract Dated 03/01/2011 - Contract Routing Number 11 FLA 29348
These provisions are to be read and interpreted in conjunction with the provisions of the
Task Order Contract specified above.
I. 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.
2. 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.
3. This Task Order Contract contains 100%State Funds.
4. 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.
5. To receive compensation under this Contract,the Contractor shall provide breast cancer screenings 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 attached Scope of Work
attached hereto as Exhibit B and incorporated herein.
6. To be considered for payment, all Women's Wellness Connection services must be entered into eCaST within
thirty(30)dyas of service being performed.Cases that exceed sixty(60) calendar days in screening length and
negatively affect the program's Core Performance Indicators may or may not be reimbursed at the discretion of
the Women's Wellness Connection Program.
7. 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.
8. The State of Colorado,specifically the Department of Public Health and Environment,shall be the owner of all
equipment as defined by Federal Accounting Standards Advisory Board(FASAB)Generally Accepted
To be attached to CDPHE Revised: 11/10/10
v 1.0 contract template
1 of 2
Exhibit A
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.
9. Contractor must notify the State within thirty(30) days of a change of the Project Director responsible for the
performance of services provided under this Task Order Contract.
10. Contractor shall participate in state-level evaluation efforts as requested by the State including, but not limited
to,progress reports on the implementation and accomplishments of the approved Work Plan in a format
provided by the State. Progress reports shall be due fifteen(15)days after each calendar quarter. Calendar
quarters shall be July 1 through September 30,October 1 through December 31, January 1 through March 31,
and April 1 through June 30,as applicable.
Failure to submit progress reports in accordance with the above time frames may result in a delay or denial of
the reimbursement request for those periods.
11. 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 CDPHE,whether in
individual,aggregate,identified or de-identified form or any other form required by CDPHE. To facilitate
follow-up, research,surveillance and evaluation,any such data collected,used or acquired shall be made
available in any form required by CDPHE,to CDPHE and any other contractor designated by CDPHE.
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 CDPHE or
as otherwise required by law. This includes a prior written request by the Contractor to CDPHE for
submission of abstracts or reports to conferences,which utilize data collected under this Task Order
Contract.
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 the Task Order Contract and in accordance with
professional standards.
12. 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.The following sponsorship information under this Task Order Contract shall be
included on all printed materials,educational materials,and paid media: "this project is sponsored by the
Women's Wellness Connection Program,at the Colorado Department of Public Health and Environment".
Any material, representation,product or other media form that will use the State's logo or information must be
pre-approved by the State. A minimum often(10)business days is required for the review and approval
process.
13. Survival of Certain Task Order Contract Terms. Notwithstanding anything in this Task Order Contract to the
contrary,the parties understand and agree that all terms and conditions of this Task Order Contract which may
require continued performance, compliance,or effect beyond the termination date of the Task Order Contract
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.
To be attached to CDPHE Revised: 11/10/10
v 1.0 contract template
2 of 2
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
DHHS 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: State Fiscal Year: Grant Funding Change Letter# CMS Routing#
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 ❑ 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 1 of 1
Effective Date:1/6/09-Rev 8/25/09
1 of 1
Exhibit B
STATEMENT OF WORK
To Task Order Contract Dated 03/01/2011 -Contract Routing Number 11 FL.A 29348
These provisions are to be read and interpreted in conjunction with the provisions of the 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
1 of 1
Attachment B-1
STATEMENT OF WORK
Project Period: April 1, 2011 through March 31, 2012.
Background: In partnership with Susan G. Komen for the Cure Denver Metropolitan Affiliate,
the Women's Wellness Connection (WWC) program provides low-income, uninsured, uninsured
and underserved clients in Colorado access to timely, high-quality screening and diagnostic
services to detect breast cancer at the earliest stages. Services are currently available through
four agencies including Boulder Valley Women's Health Center, Summit Community Care
Clinic, Tri-County Health Department and Weld County Department of Public Health and
Environment.
Direct Beneficiaries: Direct beneficiaries are men and women residing in Colorado who are
uninsured or underinsured, undocumented, meet income requirements of the program and are not
eligible for WWC.
Project Goals:
1. To deliver breast cancer screening services within the Contractor's existing network of
Subcontractors.
2. To provide quality services to clients receiving screenings.
3. Create a seamless system of breast cancer screening and diagnostic services for
Komen/WWC clients.
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.
Core Performance Indicators — Measures of clinical quality of care and penetration of screenings
in certain target populations. Indicators are set by the WWC and Komen programs.
Contractor—Agency responsible for signing and administering this contract.
WWC/Komen Statement of Work
1 of12
Attachment B-1
Definitive Diagnosis—The final point in cancer screening care where it is determined whether a
client has or does not have breast cancer. This information is usually obtained after
diagnostic services have been rendered.
Department—The Colorado Department of Public Health and Environment
Diagnostic Testing—Further testing used when a definitive diagnosis is unable to be determined
by the results of prior screening tests.
eCaST—An electronic database system the WWC program uses to track women and administer
payment to Contractors for services performed.
Network — Any provider site that works under the Contractor name and receives fiscal and
administrative assistance to do business.
Program—Women's Wellness Connection program
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.
Deliverables: Under this arrangement, the Contractor shall provide and perform the following:
1. Administration:
a. The Contractor must submit an updated list of contact information (Attachment B-1-A)
to WWC by June 29, 2011. The WWC program will request this completed document in
early June 2011 from WWC Coordinators directly, The attachment is a draft; please do
not send this completed attachment with the contract.
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 by completing the renewal form (Attachment
B-1-B) by June 29, 2011. The WWC program will request this completed document in
early June 2011 directly from the W WC Coordinators. The Attachment B-1-B is a draft;
WWC/Komen Statement of Work
2 of 12
Attachment B-1
please do not send this completed attachment with the contract.
c. The Contractor must maintain a network of Subcontractors and submit an updated list of
these Subcontractors (Attachment B-1-C) to the WWC by June 29, 2011. The WWC
program will request this completed document in early June 2011 from WWC
Coordinators directly. The attachment is a draft;please do not send this completed
attachment with the contract.
i. All Subcontractor changes during the contract year must be reported to the WWC
within fifteen (15) calendar days.
2. Network:
Ensure breast cancer screening services for eligible clients are performed by the Contractor
or through a subcontracted network of providers until a definitive diagnosis has been
achieved.
a. Subcontractors:
Service performed by Subcontractors shall:
1. 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(Attachment B-1-D). Rates
on this CPT code list will remain in effect for the length of the contract. The
WWC Program typically revises this list annually and the Contractor is
responsible for communicating rate changes to Subcontractors when they
occur.
3. Specify that only services related to breast cancer screenings on the CPT
code list will be performed and charged to the Contractor.
4. Not be charged to eligible clients 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. Clients 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
WWC/Komen Statement of Work
3 of 12
Attachment B-1
memorandum of understanding which includes the service period.
b. The Contractor must identify and support a WWC/Komen Coordinator. This person
should be the same person that serves as the WWC Coordinator.
The role of the 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 coordinator will promote and distribute the communication
of updates, policy changes, trainings, Core Performance Indicator reports, etc.
throughout the agency and to necessary staff.
iii It is expected that the coordinator will be responsible for clinical quality
performance at the agency level (as demonstrated in the Core Performance
Indicator report) and update eCaST data as needed to keep the agency in
compliance.
c. The Contractor must identify and support a WWC/Komen Data Coordinator.
The role of the data coordinator is to ensure that all information about clients
screened under the WWC/Komen Program is entered into eCaST.
ii It is expected that the data coordinator will maintain data in eCaST that is up to
date and meets Core Performance Indicators.
iii The WWC/Komen Coordinator role and WWC/Komen Data Coordinator role
may be filled by the same person at the agency.
3. Enrollment: The Contractor must ensure that clients screened under the WWC/Komen
program meet WWC/Komen program eligibility requirements:
a. WWC/Komen Program Eligibility Requirements (Attachment B-1-E).
Eligibility guidelines may be updated during the period this scope of work is in
effect. When new eligibility guidelines are adopted for implementation by
WWC, the Contractor will be notified and responsible for implementing
necessary changes to the Contractor workflow by a date determined by WWC.
ii Contractors should provide eligibility screenings and referrals in Spanish or other
languages as requested by clients served.
b. Document lawful presence status in eCaST for each client in eCaST(see section 8
eCaST System). (Attachment B-I-F)
WWC/Komen Statement of Work
4 of 12
Attachment B-1
4. Billing and Reimbursement:
a. The Contractor shall only request reimbursement from the WWC/Komen pilot project
for a case that meets eligibility, timeliness, performance and data requirements.
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 has been entered in eCaST.
c. Reimbursement is determined by the outcome of the case. Payment will be determined
based on the highest level of care provided to the client(Attachment B-1-G).
i. Cases that exceed sixty (60) days in length from screening to definitive diagnosis
and negatively affect the program's Core 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 client,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/Komen
contracting agency is involved with the same woman, the Contractor who closes
the case will receive all of the WWC or Komen funds at the highest level
achieved.
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:
Enrollment of women into the WWC/Komen Program;
ii Cancer screening services, including a 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;
vi Administrative procedures to place women with a positive diagnosis of breast
WWC/Komen Statement of Work
5 of 12
Attachment B-1
into the Medicaid Program if eligible; and
vii Administrative procedures to enroll clients diagnosed with breast cancer that are
not eligible for Medicaid into treatment services through Komen or other
community-based efforts.
e. Data entered into eCaST is the basis for calculating reimbursement for each woman
screened.
Data for any WWC/Komen procedure must be entered into eCaST within thirty
(30) days of service being performed. Cases entered after this thirty (30) day
period may or may not be paid at the discretion of the WWC.
ii The Contractor shall review Report 22S - Incomplete Cases Not Yet Paid to
identify women who are pending services, or who may have missing essential
information prior to the fourteenth (14th) of each month.
I. 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 client's electronic record may make
him/her ineligible for payment.
3. Procedures entered into eCaST must be charged to the correct program
(Komen or WWC) in order to be paid. The Contractor shall follow the
Komen/W WC Funding Diagram (Attachment B-1-H) to determine which
program to charge each service to.
f. One Komen 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.
The Contractor will work with WWC Program staff directly on non-payment of
clients screened. If WWC staff is unable to rectify reimbursement, the Contractor
will work with the W WC fiscal officer to the point of satisfaction by both parties.
ii Contractors will each be given a funding cap which appears on Page I of the
Contract(this varies by Contractor)for direct care screening services. WWC
will notify Contractors on a monthly basis regarding how funds are being
expended and assist with making decisions to stop, slow down or make changes
WWC/Komen Statement of Work
6 of 12
•
Attachment B-1
to accommodate this funding cap. Contractors should run on a monthly basis
eCaST Report 24S - Supplemental Count of Women Paid for an unduplicated
count of Komen clients paid and Report 72S - Service Delivery Grant Payment
Supplemental to keep track of Komen funds expenditure.
g. WWC may reimburse the Contractor for above and beyond costs outside of the level
reimbursement system with Komen funds. Any procedures provided outside of the
approved procedures on the CPT code list(Attachment B-1-D) must be pre-approved
by a WWC staff member and must be charged to the WWC/Komen program at current
Medicare rates. Procedures must also be entered into eCaST.
5. Service Delivery:
a. The Contractor shall follow and utilize all policies and guidelines according to the 2010-
2011 WWC Provider Toolkit, http://www.cohealthsource.org/resource-librarv/diuital-
resources/digital-resource---toolkits.aspx, and Komen screening guidelines,
Ott p•//ww5 kornen org/BrcastCancer/GeneralRcconlmendations.html), as the standard
of care when performing services related to breast cancer screening.
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 by WWC agencies, the Contractor will be notified and
responsible for implementing necessary changes by a date determined by the
WWC.
b. The Contractor shall implement the breast cancer screening algorithms as approved by
the program as clinical guidelines for breast cancer screenings.
c. The Contractor may utilize the WWC Nurse Consultant for clinical consultation services
on any client.
6. Performance Standards:
a. The Contractor will meet or exceed established Centers for Disease Control and
Prevention (CDC) Clinical Core Performance Indicators for abnormal breast cases
(Attachment B-1-I).
Contractors exceeding, meeting or not meeting indicators/reports will be
WWC/Komen Statement of Work
7 of 12
Attachment B-1
contacted by the WWC.
1. Contractors not meeting Core Performance Indicators 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.
2. Contractors exceeding indicators will be recognized for good performance.
7. Site Visits:
a. The WWC/Komen program will perform site visits to select Contractors on an annual
basis. The purpose of a site visit is to provide, promote and ensure quality breast 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 the following:
Core Performance Indicators;
ii eCaST data reports, specifically Report 17 - Missing Data and Report 84 —Breast
Diagnostic Follow up;
iii Technical assistance needs;
iv Adherence to this Statement of Work;
v Participation in trainings, conference calls and webinars; and
vi Ability to refer positively diagnosed clients to Medicaid (or other) treatment in a
timely manner when eligible.
c. Site visits will include:
Completion of the WWC prep tool (see Quality Improvement and Assurance at
http://www.cohealthsource.org/prourams/women's-wellness-
connection/provider-information.aspx);
ii Chart audit;
iii Review of Subcontractor agreement(s);
WWC/Komen Statement of Work
8 of 12
Attachment 8-1
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
Core 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 visit.
e. Site visit evaluations may be used as part of, but will not be a substitute for, the quarterly
Contract Management System (CMS) evaluations.
8. eCaST System:
a. WWC will provide training on the data system to the Contractor, its administration staff,
fiscal staff and provider site staff as needed or requested by the Contractor.
Any changes to staff that are responsible for data entry of WWC information must
be reported to the Department within fifteen (15) days.
ii New provider site staff must be trained by WWC on eCaST within thirty(30)
days of hire.
b. Forms used to collect eligibility and enrollment information will be electronically
furnished by WWC. For Komen only funded clients, Contractors may use their own
forms or forms jointly created with the WWC and the Contractor to obtain required
information for data entry into eCaST.
c. Each client should be screened for lawful presence status. (Attachment B-1-F)
For those who are undocumented:
Leave the checkbox titled "Verified Legal Presence" in eCaST blank.
ii The Contractor may use their own address for undocumented clients in eCaST.
iii Name, birth date, income and insurance status need to be accurate in eCaST.
For those who meet lawful presence requirements:
Check the checkbox titled "Verified Legal Presence in eCaST."
ii If the patient is eligible for WWC, follow WWC requirements for lawful presence
verification.
9. Communication:
WWC/Komen Statement of Work
9 of 12
Attachment B-1
a. When corresponding with the WWC. Contractors must use all privacy and security
measures to protect the client's personal health information.
Accepted forms of communication include:
1. WWC/Komen identification number used in all email conversations
2. Mail or fax clearly marked "Confidential"
3. Health Insurance Portability and Accountability Act(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 the WWC
program.
b. At least one representative from the Contractor and/or its network provider sites should
attend meetings hosted by WWC staff to ensure compliance with this contract.
WWC will attend conference calls and meetings as needed and upon special
request of the Contractor. (Attachment B-1-J)
ii WWC will provide Contractor with a "monthly data snapshot" which includes
data on numbers screened, spending, average costs, patient demographics,
abnormal rates etc. to assist Contractors with managing their programs
effectively.
10. Medicaid Treatment for WWC Clients Diagnosed with Cancer
a. The Contractor will refer WWC eligible women with a positive diagnosis of breast
cancer to Medicaid.
Contractor personnel must follow the STEP Enrollment Process (Attachment B-
1-K). This document may also be found by navigating to Medicaid BCCP, Step
List at http://www.cohealthsource.org/programs/women's-wellness-
connection/provider-information.aspx.
ii Contractor will fax initial completed paperwork(WWC Personal History form
(Attachment B-1-M), WWC Rules Form (Attachment B-1-N), Lawful
Presence affidavit(Attachment B-1-F) and pathology report confirming the
diagnosis)to WWC within five (5) business days of cancer diagnosis.
Women referred to Medicaid must be completely entered into eCaST within
twenty-four (24) hours of diagnosis.
WWC/Komen Statement of Work
10 of 12
Attachment B-1
iv Contractor will fax final completed paperwork (Medicaid application signature
page and presumptive eligible form) to WWC within five (5) business days of
receiving approval for presumptive eligibility.
v Contractors will ensure applications are submitted to local Social Service
agencies within thirty (30) business days after diagnosis.
vi With the approval of the woman, a patient with a positive diagnosis can be
referred to a treatment navigator.
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. Updated
documents may also be located by navigating to Medicaid BCCP, Step List at
http://www.cohealthsource.org/prourams/women's-wellness-connection/provider-
information.aspx.
c. For clients diagnosed with breast cancer that are not eligible for Medicaid, Contractors
are required to enroll clients in treatment services through Komen or other community-
based efforts.
11. Contract Management System (CMS) Evaluations
a. 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. 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.Please see the
notification memo for further information (Attachment B-1-L).
12. Reporting to the Susan G. Komen for the Cure Denver Metropolitan Affiliate
a. Contractors will not be required to submit reports directly to Komen.
WWC/Komen Statement of Work
11 of 12
Attachment B-1
b. WWC will submit monthly reports, mid-year and end of year reports to Komen on the
Contractor's behalf.
c. Feedback from Contractors may be required to complete these reports.
WWC/Komen Statement of Work
12 of 12
Attachment B-1-A
Contractor Contact Information
The WWC program will request this completed document in early June 2011 from WWC Coordinators
directly. This attachment is a draft; please do not send this completed attachment with the contract.
Contractors cannot begin work under this contract until this form is received by the WWC.
1 of 3
Attachment B-1-A
Agency Contacts Verification Fiscal Year 2011-2012
Agency # ****************************
Legal Name ****************************
Phone: ######-#### Fax: ######-####
Physical Address Mailing Address
******************** ********************
******************** ********************
Agency Director ,_' ********************
Phone: ********************
Fax: ********************
Email: ********************
Contract Administrator H ********************
Phone: ********************
Fax: ********************
Email: ********************
eCaSTCoordinator J ********************
Phone: ********************
Fax: ********************
Email: ********************
Fiscal Manager ll ********************
Phone: ********************
Fax: ********************
Email: ********************
Payment Coordinator ❑ ********************
Phone: ********************
Fax: ********************
Email: ********************
Signature Authority ll ********************
Phone: ********************
Fax: ********************
Email: ********************
WWC Coordinator ********************
Phone: ********************
Fax: ********************
Email: ********************
Instructions: 1) Please verify your Agency Contact information at the beginning of this report. If any information is
incorrect, please send the correct information on this sheet or on another sheet. 2) Please verify the contacts by
checking the box next to the contact type if the correct person is listed. If any information is incorrect or missing,
please send the correct information on this sheet or on another sheet. Use 201 I WWC Contacts Descriptions for
explanations of responsibilities of each contact type.3) Email this report to kris.mccracken@state.co.us or fax to
303-758-3268 by June 29,2011.
2 of 3
Attachment B-1-A
Agency Contacts Verification Fiscal Year 2011-2012
Instructions: 1) Please verify your Agency Contact information at the beginning of this report. If any information is
incorrect, please send the correct information on this sheet or on another sheet.2) Please verify the contacts by
checking the box next to the contact type if the correct person is listed.If any information is incorrect or missing,
please send the correct information on this sheet or on another sheet. Use 2011 WWC Contacts Descriptions for
explanations of responsibilities of each contact type.3) Email this report to kris.mccracken@state.co.us orfax to
303-758-3268 by June 29,2011.
3 of 3
Attachment B-1-B
Contractor eCaST Annual Security Renewal Form
The WWC program will request this completed document in early June 2011 from WWC Coordinators
directly. This attachment is a draft; please do not send this completed attachment with the contract.
Contractors cannot begin work under this contract until this form is received by the WWC.
1 of 2
STATE OF COLO Alt OB
John W.Hickenlooper,Governor
Christopher E.Urbina,MD,MPH OF'co o
Executive Director and Chief Medical Officer 9p1
Dedicated to protecting and improving the health and environment of the people of Colorado
. " <
4300 Cherry Creek Dr.S. Laboratory Services Division 816t'/
Denve
r,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 and Environment
WOMEN'S WELLNESS
connection
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 06/29/2011, 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.thomas!a?state.co.us, or the data manager, Christen Lara, at 303-692-2531 or
christen.lara'nstatc.co.us.
2 oft
Attachment B-1-C
Contractor List of Current Subcontractors
The WWC program will request this completed document in early June 2011 from WWC
Coordinators directly. This attachment is a draft; please do not send this completed attachment
with the contract. Contractors cannot begin work under this contract until this form is received
by the WWC.
1oft
Attachment B-1-C
WWC Subcontractor Verification - Fiscal Year 2011-12
Please fill this out for each subcontractor NOT listed for your agency.
New Subcontractor Name:
Corporate Information:
Mailing Address:
City: State: Zip:
County:
Contact:_ Phone:
Clinic Information:
Mailing Address:
City: State: Zip:
Contact: Phone:
All sites using this subcontractor:
New Subcontractor Name:
Corporate Information:
Mailing Address:
City: State: Zip:
County:
Contact: Phone:
Clinic Information:
Mailing Address:
City: State: Zip:
Contact: Phone:
All sites using this subcontractor:
2 of 2
Attachment B-1-D
2011-2012 Women's Wellness Connection CPT Code List
Procedure CPT CO Professional Technical
CODE RATE Component Component
SCREENING PROCEDURES
Screening Mammogram Analog 77057 $ 79.79 $ 35.24 $ 44.55
^Screening Mammogram Digital G0202 $ 127.74 $ 34.53 $ 93.21
Clinical Breast Exam (CBE) 99203 $ 45.24
Pelvic Exam 99203 $ 45.24
Conventional Pap Smear 88164 $ 15.42
Thin Prep(Liquid based) Pap 88142 $ 29.58
Pap with physician interpretation 88141 $ 26.70
"As funds allow, WWC will reimburse a capped rate of$12.71 per digital screening mammogram. Must be
documented in eCaST.
BREAST DIAGNOSTIC PROCEDURES
Imaging
Diagnostic Mammogram/Unilateral 77055 $ 83.14 $ 35.24 $ 47.90
Diagnostic Mammogram/Bilateral 77056 $ 105.48 $ 43.75 $ 61.73
Breast Ultrasound 76645 $ 88.94 $ 27.09 $ 61.85
Consult or Repeat CBE
Surgical consult 99243 $ 122.69
Repeat CBE 99242 $ 89.28
Biopsy
Excisional Biopsy
Excision of breast lesion identified by: preop placement 19120 $ 405.32
of radiologic marker
OR
Excision of breast lesion 19125 1 $ 448.66
AND
Pre-op placement of needle loc wire 19290 $ 150.82
Pre-op placement of needle loc wire, radiologic 77032 $ 58.41 $ 28.17 $ 30.24
interpretation and supervision
Radiologic examination specimen 76098 $ 19.35 $ 8.15 $ 11.20
Biopsy interpretation 88305 $ 102.37 $ 36.69 $ 65.68
1 of 4
•
Attachment B-1-D
Procedure CPT CO Professional Technical
CODE RATE Component Component
Stereotactic Core Biopsy
Breast bx, needle core, not using imaging 19100 $ 123.56
OR
Breast bx, incisional 19101 $ 281.50
AND
Stereotactic localization, each lesion, radiologic 77031 $ 187.84 $ 79.82 $ 108.02
supervision and interpretation
Radiologic examination specimen 76098 $ 19.35 $ 8.15 $ 11.20
Biopsy interpretation 88305 $ 102.37 $ 36.69 $ 65.68
.C;4r
U/S Guided Core Biopsy
Breast biopsy, percutaneous needle core, using 19102 $ 203.46
imaging guidance
AND
US Guidance for Cyst Aspiration, Radiologic 76942 $ 181.01 $ 33.80 $ 147.21
Supervision and Interpretation
Biopsy interpretation 88305 $ 102.37 $ 36.69 $ 65.68
Stereotactic Vacuum Assisted Biopsy
Automated vacuum assisted bx 19103 $ 512.83
Tissue marker placement 19295 $ 84.31
Post procedure mammogram 77055 $ 83.14 $ 35.24 $ 47.90
Stereotactic localization, each lesion, radiologic 77031 $ 187.84 $ 79.82 $ 108.02
supervision and interpretation
Radiologic examination specimen 76098 $ 19.35 $ 8.15 $ 11.20
Biopsy interpretation 88305 $ 102.37 $ 36.69 $ 65.68
Other Sampling
Cyst Aspiration
*Cyst Aspiration 19000 $ 101.20
*US Guidance for Cyst Aspiration, Radiologic 76942 $ 181.01 $ 33.80 $ 147.21
Supervision and Interpretation
FNA by Palpation
FNA without image guidance 10021 $ 1.25.04 _
Eval of FNA 88172 $ 51.19 $ 29.26 $ 21.93
Interpretation and Report of FNA 88173 $ 130.11 $ 67.39 $ 62.72
2 of 4
Attachment B-1-D
Procedure CPT CO Technical
Professional
CODE RATE Component Component
U/S Guided FNA
FNA with image guidance 10022 $ 128.51
Eval of FNA 88172 $ 51.19 $ 29.26 $ 21.93
Interpretation and Report of FNA 88173 $ 130.11 $ 67.39 $ 62.72
Additional allowable procedures-please submit these procedures quarterly to WWC Data Manger
Breast biopsy interpretation with margins 88307 $ 205.02 $ 78.05 I $ 126.97
Excisional Biopsy- addt'I lesion 19126 $ 144.87
Excisional Bx-addt'I lesion/ needle loc wire 19291 $ 65.15
*Aspiration of cyst, additional 19001 $ 25.38
Surg path,first tissue block, froz spec 88331 $ 87.34 $ 58.87 $ 28.47
Surg path,ea. Addt'l block 88332 $ 39.02 $ 28.90 $ 10.12
Anesthesia for procedures 00400
Supplies & materials not usually provided 99070
CERVICAL DIAGNOSTIC PROCEDURES
HPV Testing 87621 $ 51.25
GYN Consult 99243 $ 122.69
Colposcopy
Colposcopy without Biopsy I 57452 I $ 85.45
Colposcopy with Biopsy
Colposcopy with Biopsy and/or ECC 57454 $ 143.46
Biopsy interpretation 88305 $ 102.37 $ 36.69 1 $ 65.68 I
*Colposcopy with loop electrode biopsy 57460 $ 277.01
Loop Biopsy interpretation and dissection 88307 $ 205.02 $ 78.05 I $ 126.97 I
*Colposcopy with loop electrode conization 57461 $ 310.65
Loop Biopsy interpretation and dissection 88307 $ 205.02 $ 78.05 1 $ 126.97 I
•
Other Cervical diagnostic procedures
*Cone Biopsy
Conization of the cervix, cold knife or laser 57520 $ 284.41
Biopsy interpretation and dissection 88307 $ 205.02 $ 78.05 1 $ 126.97 I
3 of 4
Attachment B-1-D
Procedure CPT CO Professional Technical
CODE RATE Component Component
*Endometrial Biopsy
Endometrial sampling w/or w/out ECC 58100 $ 102.28
Biopsy interpretation and dissection 88307 $ 205.02 $ 78.05 I $ 126.97
`dot;.q
*LEEP/LOOP
Loop electrode excision 57522 $243.44
Loop Biopsy interpretation and dissection 88307 $ 205.02 $ 78.05 $ 126.97
Additional allowable procedures-please submit these procedures quarterly to WWC Data Manger
Anesthesia for procedures 00400
Supplies & materials not usually provided 99070
Due to Federal policy WWC cannot fund these procedures
CAD, diagnostic 77051 $ 11.93 $ 3.11 $ 8.82
CAD, screen 77052 $ 11.93 $ 3.11 $ 8.82
Cervical polypectomy 58558 $ 301.84
Diagnostic mammography digital, bilateral G0204 $ 150.20 $ 42.68 $ 107.52
Diagnostic mammography digital, unilateral G0206 $ 119.28 $ 34.53 $ 84.75
ductogram, multiple duct 77054 $ 100.15 $ 22.77 $ 77.38
ductogram, single duct 77053 $ 74.29 $ 18.10 $ 56.19
MRI, bilateral 77059 $ 881.73 $ 81.87 $ 799.86
MRI, unilateral 77058 $ 821.21 $ 81.87 $ 739.34
4 of 4
Attachment B-1-E
Women's Wellness Connection/Komen Program Eligibility Requirements
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(see table)
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
more than 8 $7,840+ add $796 $94,075+add$9,550
for each person for each person
*As defined by the Bureau of the Census for statistical purposes, a household consists of all the
persons who occupy a housing unit (house or apartment), whether they are related to each other
or not. If a family and an unrelated individual, or two unrelated individuals, are living in the
same housing unit,they would constitute two family units, but only one household.
**DH-IS Federal Poverty Guidelines change annually by January.
*** Size of Family Unit supported by Total Gross Household Income. Gross income is money
made by individual BEFORE taxes.
Source:Federal Register/Vol. 76,No. 13/January 20, 2011:
htio://w►m+'.fe deralre gister.gov./articles/2011/01/20/?011-1237/annual-update-[J the-hhs-poverty-
guidelines
• Lack health insurance, have health insurance that does not cover screening exams, or
have a high deductible/co-pay 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 (I-551)
o Other forms of ID are also acceptable, please see:
http://www.colorado.gov/cs/Satell ite/Revenue-Main/XRM/12 1 6289012 125
1 of 2
•
Attachment B-1-E
• 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
To qualify for Komen only paid services, clients must:
• Be at or below 250% of the Federal Poverty Level (see table)
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
more than 8 $7,840 + add $796 $94,075+ add $9,550
for each person for each person
*As defined by the Bureau of the Census for statistical purposes, a household consists of all the
persons who occupy a housing unit (house or apartment), whether they are related to each other
or not. If a family and an unrelated individual, or two unrelated individuals, are living in the
same housing unit, they would constitute two family units, but only one household.
**DHHS Federal Poverty Guidelines change annually by January.
*** Size of Family Unit supported by Total Gross Household Income. Gross income is money
made by individual BEFORE taxes.
Source: Federal Register/Vol. 76, No. 13/January 20, 2011:
htip://www.lederalregister.gogiartieles,/201 I/01/20:2011-1237/Onnuttlnendaie-of-the-hhs-
poverty-guidelines
• Lack health insurance, have health insurance that does not cover screening exams, or have a
high deductible/co-pay significant enough to delay or refuse screening
2 of 2
. 5 •
Attachment B-1-F
Women's Wellness Connection Legal Presence Affidavit - English
(Copy onto 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):
I 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:
1 of 2
Attachment B-1-F
Women's Wellness Connection Legal Presence Affidavit- Spanish
(Copy onto agency letterhead)
Verification de presencia legal DECLARACION
Yo, , afinno 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 federales.
Entiendo que para dar cumplimiento a la ley, esta declaration bajo juramento es necesaria
para solicitar la prestacion 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
prestacion de un servicio publico de manera fraudulenta.
Firma: Fecha:
2 of 2
I V
Attachment B-1-G
Women's Wellness Connection Level Reimbursement Fee Structure*
LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4
Definition Clinical Breast Results of all tests Results are Results are
Exam exam only. are normal and abnormal and abnormal, requiring
Result is normal require no further require further non- additional invasive
and requires no action. Enrollment invasive diagnostic diagnostic testing.
further action. and data entry fee testing. The The definitive
added. definitive diagnosis diagnosis may be
is non-cancerous. cancer or non-
Case management cancer. An
fee added. additional case
management fee
added.
BREAST $75 $190 $505 $1405
CANCER
SCREEN
Reimbursement
*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.
1 of 1
J 00 0 `0
m 3 c -C L
v E
3 v E v
E `0 5 P'. 5 3 a
'2 b
t v m u c 3 v a
Q E e .. U V .� A y � c 'G_
i. N u n a' T y
0
u ">' cua Lai am c.' ; 0 c ., E LI
3
j _ 3 2 `o o , m E m ,_ o. E c ` ._ca 3
c ...2'125' 0
3 ' L 'n E C T W 7) M C O O
—_ -1-' E C 4.:1) ro O t .,, E o
zv c ' Eve .= au. 8 $ " En0 .- :.L180.0 .4 `. et!
0
0 0o c A N o C v c 3 c C c 3 a E n A G— 0 E 0
u < 7 -] ry Z oo EUa ° a c E-cr to 3 o, 0Uccc (Ja .^0- rn o ._
c u E • • • ° 'E U U c u
on _ E3ro 3 - v
3 3E ¢ 5 3 3 3 < 2
u E
L N
U u 00 j
3 EE
°I 00 `m Yoo ` y EAc'
E
y o E a v o o Z h E ; '°
L CJ V L T c 0 E yV. V+ 5 c V V)
au Ec c a> a o u ° a c> u ,
cC d v u L .L+ :Cu O E P '>
Q x J e O c O �, - V c .5 `Y -O 0
I:
W .p c c 2 E E °
t- 3 toe c` ^�
G Y c N L ,y G u y ° 's E u m W e E
'O `o `o E .c .c E4 - u�. E z J u
7 OL -a V c G 0. E T L' o o cc E : ' e c = ==0 o c. _
:z. c m o o — " E m a' E U c e c. c c 0 o u E ° 8 0 _ _
G Cle ,, v .c = o E C 0. •= >,`:° a ? E c y W G'_ c v E te•:- .o o r u •• c
v RI v oo E E (-4 o c E 0 c i m w `u 4 e u a m e . o _ b4 cn E
O c E < '� .2Z op c < ZZ L A m^0 o4a a < o. E2 e) co, >. m c "r,
ct W c G 00 r.
p p O y E V U G O G
•Y• " E • • • c E 2 U • • • • • • U o E U
U o of 3 3EE3
3 3E ` AE3 3 3Y E3
c23
o 2 u a•-.4 a rIL. $ u o
. - ,o rC o v a ten
o 1-321'' - E C a = C OOaC
.0 cm m Le C u .n 'J ` J cc: 2
7a O 0 >. ._ O '
C .'1
0 v c
� Fi V U ' t 0 u O . to.E i O K 0
C 15
s 3 E c a � v ch_na c N ? N ✓mac � v
3 le 5, o
— 0
° ' u c v o 0 (7 m m m m o c _ u m
o 0 0 - 1 .040 t ≥ ` 0 ery a' E ,u
, c q '= 00C. m 0 W a — 2 'S r
G v v C o
4' c . c C' ; U .O .'
E E @ E
O Q c
• • • L/0 22E Y < M
i E
V L
' Ou c o v y y pp
e J O C
v cki.� Cr y > CI > > c
W L V] E V G V Gi m
Attachment B-1-I
Example of Core Performance Indicators Report from eCaST
a .
ir Colorado nenartmpnt of Public Health and Fnvironment
WOMEN'S WELLNESS 80- Core Indicator Report
connection
REPORT PARAMETERS
Dates tom: 04.'0'2307 to: 03i31i2C38
Agency:
Agency Standard Slate Standard
Program Performance Indicators Standard Count Populatioi Percent Meld Count Population Percent Met?
llawdees widkatoes
Rarely or Never Screened at;rstaf Pap Test 2Cri. I 1 51 21.6 1 t 875 3,092 28.3 Ye'
lhik.sown at metal Pao Test 5`A •3 51 25.5 11O 296 3,092 9.2 40
5creentrig mammograms;rev41e7 to women.=k7 years 75'4 4 t 68 60.3 Nu 4.593 7,357 56.i rug
Mar
Genies(Cow t3ispiestle lrikabm
Atnxtnaf Screenings w+ttiCompete Fattvw•ip 90c� 5 7 71 4 No 82 136 60.3 No
Tome from saeeneig to dugnosrs>60 days Ice a.ne mal 25Y 1 4 25.0 Yel 17 63 27.0 r+o
saeeu,g results
BMW C4aaaOGpwat idk ois
Ann>mat screenng'mutts+.stn complete lotvx-u 90% !0 21 47.6 x, 1,346 1,619 83.1 Stu
Taw Item soex ixig to dctgiiasis>60 days Iv a'Jitermai 25% 2 19 10.5 Yu, 23 1 7= 1.3 Ye'
L.«•oanh1'ae t IC
1 13::XM 2 b 7tl>s4i rlsree el(). Can F•ideata Reoar f a s UO144
1 of 1
e. •
Attachment B-1-J
Schedule of Conference Calls and Trainings
2011-2012
Health Improvement Team (HIT) Calls
Conference call information:
1. Dial the Conferencing access number: 1.866.633.3380
2. Dial the Conferencing room number: *7829178* (note the "*"before and after the
room number).
3. Wait to be added to the conference
Webinar login information:
1. Log onto www.gwestconterncing.com
2. Dial the conference room number: *7829178* (note the"*" before and after the room
number).
3. Follow online instruction to be connected to web and audio portions of webinar
Call Date Call Time Call Topic Facilitator
4/21/11 11:00-11 :45 am TBA TBA
5/19/11 11:00-11 :45 am TBA TBA
6/16/11 11:00-11:45 am TBA TBA
7/21/11 11.00-11:45 am TBA TBA
8/18/11 11:00-11:45 am TBA TBA
9/15/11 11:00-11 :45 am TBA TBA
10/20/11 11:00-11:45 am TBA TBA
11/17/11 11:00-11 :45 am TBA TBA
12/15/11 11:00-11 :45 am TBA TBA
1/19/12 11:00-11:45 am TBA TBA
2/16/12 11:00-11:45 am TBA TBA
3/16/12 1 1:00-11 :45 am TBA TBA
At least one representative from the Contracting agency is required to attend 50% of HIT calls.
Call reminders are sent out to WWC coordinators by WWC staff at least one week ahead of each
call.
Clinical Webinars
Clinical webinars are hosted quarterly by the Women's Wellness Connection. Notices about
these webinars are sent out 1 month and 1 week ahead of time with webinar entry instructions,
speakers and topics. Webinars are typically held on a Wednesday from 12:00-1:30. Clinicians
are encouraged to attend.
At least one representative from the Contracting agency is required to attend 75% of clinical
webinars. A copy each live webinar is saved on the Women's Wellness Connection website.
Contractor staff may listen to these webinars at any time after they occur and should notify
1 of 2
Attachment B-1-J
WWC staff if a webinar was listened to at a later time for attendance purposes.
Webinar login information:
1. Log onto www.gwestconferncing.com
2. Dial the conference room number: *7829178* (note the "*"before and after the room
number).
3. Follow online instruction to be connected to web and audio portions of webinar
eCaST Users Group Webinars
Call Date Call Time Call Topic Facilitator
3/28/11 2:30—3:30 pm TBA TBA
5/25/11 2:30— 3:30 pm TBA TBA
7/27/11 2:30—3:30 pm TBA TBA
9/28/11 2:30 — 3:30 pm TBA TBA
11/23/11 2:30—3:30 pm TBA TBA
1/25/12 2:30-3:30pm TBA TBA
1/25/12 2:30—3:30 pm TBA TBA
At least one representative from the Contracting agency is required to attend 50% of eCaST
webinars. Call reminders are sent out to WWC coordinators and eCaST coordinators by WWC
staff at least one week ahead of each webinar.
Conference call information:
1. Dial the Conferencing access number: 1.866.633.3380
2. Dial the Conferencing room number: *2443243* (note the "*" before and after the
room number).
3. Wait to be added to the conference
Webinar login information:
1. Log onto www.gwestconferncing.com
2. Dial the conference room number: *2443243* (note the "*" before and after the room
number).
3. Follow online instruction to be connected to web and audio portions of webinar
2 of 2
Attachment B-1-K
Women's Wellness Connection
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 contact the WWC Nurse Consultant at 303-692-2323.
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:
LI 40-64 years of age
LI 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.gov/cs/Satellite/Revenue-Main/XRM/12162890 2524)
LI Does not have health insurance or has health insurance that will not cover breast or
cervical cancer treatment.
The BCCP enrollment process cannot proceed until all data is entered into eCaST.
STOR 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/BCCPEligibilitvChart.pdf
If your pathology report has a diagnosis that is NOT on this list, please consult with
STOP WWC Nurse Consultant at 303-692-2323 before deciding not to proceed.
STEP 3—Obtain Approval from WWC
Fax ONL I the following to the WWC Nurse Consultant at(303)758-3268.
❑ Personal History Form (must be complete)
❑ WWC Rules Form
❑ Pathology report(s) (Please only send the report that confirms the diagnosis)
LI Signed lawful presence affidavit.
1 of 3
Attachment B-1-K
`' Eligibility must be confirmed by WWC staff BEFORE you call the PE Hotline. A
Sb.O• 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
Do not attempt to get the PE number for the client until you have received approval
STOP 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.
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:
English
http://www.co lorado.eov/cs/Satellite?b lobco l=urld ata&blobheade r—application%2 Fpdf&bl ohk
ev=id&hlobtable=MungoBlobs&blobwhere=1251 64091 1 378&ssbinary=true
Spanish
http://www.colorado.ov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobk
ev=id&blobtable=MungoBlobs&hlobwhere=1251652374979&ssbinary=true
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 the WWC Nurse Consultant (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. 2 of 3
•
.. .
Attachment B-t-K
• 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
❑ 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.pdf
❑ 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.
If this step is not completed correctly, the woman will be dropped from Medicaid
STOP once her PE period is over(usually 45 days).
STEP 6—Contact Treatment Navigator
WWC contracts with the Andre Center for breast and cervical cancer education and for
treatment navigation services. This service is available to WWC women free of charge. A
treatment navigator can assist women in making decisions on next steps in her battle against
cancer. Referrals can be made to the Andre Center by using the following steps:
1. Call 303-388-2441 to let them know verbally that you are referring a client. It is
important for the referring site to contact the Andre Center and not the patient because
the Andre Center will need to get specific medical information from the referring site in
order to assist the patient effectively.
2. Download the Protective Health Information form from the website
www.andrecenter.org. By having the woman sign the form, this allows the woman's
personal health information to be given to the Andre Center
3. Fax to following forms to the Andre Center 303-355-2675:
a. Signed release form
b. Mammogram(s), ultrasound, biopsy report, other tests and pathology reports.
STEP 7—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.
3 of 3
Attachment B-1-L
Contract Management System Notification
MEMORANDUM
Effective July I, 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 1, 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.polk@state.co.us
Deb Polk, Contract Performance Manager
Colorado Department of Public Health and Environment
1 of 1
M �
Women's Wellness Connection ° ;'aimentB-1-M .�c
PATIENT HISTORY FORM WOMEN'S •WELLNESS Cole
connection ofPu6ur�den
(Patients must reapply every year) and Environment
r
+1:9F,i a i+'=-ste i a �ws. s#9p[: i. �.... S -:..:a 6'�Kal. O .i..:.-)♦
AGENCY# CHART# W W C#
ENROLLMENT/RE-ENROLLMENT DATE ❑ I HAVE VERIFIED THIS PATIENT'S LAWFUL PRESENCE DOCUMENTATION IS CURRENT.
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
O
I-
Q WHAT ETHNICITY ARE YOU?CHOOSE ONE BELOW.
❑ I am Latina and/or Hispanic. ❑ I am not sure if I am Latina or Hispanic, ❑ I am not Latina or Hispanic.
LL
I—
w WHAT RACE(S)ARE YOU?CHECK ALL THAT ARE TRUE.
❑Black/African American U Asian ❑Pacific Islander
❑White ❑Alaska Native ❑I am not sure
❑American Indian ❑Aleutian Islander ❑Other.
O Latina/Hispanic U Native Hawaiian
DO YOU HAVE PRIVATE INSURANCE OR DO YOU HAVE MEDICARE? WOULD YOU LIKE US TO SEND YOU A LETTER
MEDICAID? ❑Yes,partA only. REMINDING YOU OF YOUR SCREENING?
O Yes, I have Medicaid. ❑Yes,parts A and B. (test phase only)
U Yes,I have private insurance. ❑No,I do not have Medicare. J Yes
Check below if any are true. U In English
O but I have a high deductible. J In Spanish
❑but it does not cover cancer screening. U No,I do not want a letter reminding me of my
❑No,I do not have private insurance. screening.
• ❑No,I do not have Medicaid.
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?
❑Brochure/Poster ❑Hotline(866-951-9355) J TV Ad
❑Clinic Staff/Physician J Newspaper Ad J Women's Wellness Connection event or
❑Friend/Family Member U Patient Navigator staff person
J Health Fair ❑Radio Ad ❑Other:
PLEASE PROVIDE THE FOLLOWING NUMBERS WE CAN REACH YOU AT: Mailing Address
Q Home Phone number City State Zip
I-
z
O Work Phone number County
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, A5 — Denver, Colorado 80246-1530
• w
cozot
Women's Wellness Connection
apt'?l invent B-1-M �¢e
FORMULARIO DE ANTECEDENTES DEL PACIENTE WOMEN'S WELLNESS `°loradon of en,
(Los pacientes deben volver a presentar la solicitud todos los ahos) mdEswinnmmr
da• ,t„.. _. ..:::® ._.�rli Asa- S. ,® ® r.a �,: +.va:- 1•.. . .. ,�
PARA USO EXCLUSIVO DEL PERSONAL DE LA CLINICA
AGENCY# CHART# WWC#
ENROLLMENT/RE-ENROLLMENT DATE 7 I HAVE VERIFIED THIS PATIENTS LAWFUL PRESENCE DOCUMENTATION IS CURRENT.
INSTRUCCIONES PARA EL PACIENTE:Complete coda parte a continuociOn.Las areas sombreadas se deben completar 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
4 QUE ORIGEN ETNICO PERTENECE?ELIJA UNO A CONTINUACION.
S ❑ Soy latina y/o hispana. ❑ No estoy segura de si soy latina o hispana. LI No soy latina ni hispana.
LL
It QUE RAZA(S)ES USTED?MARQUE TODO LO QUE SEA VERDADERO.
2 ❑Negra/afroamericana ❑Asidtica ❑Proveniente de las Islas del Pacifico
❑Blanca ❑Nativa de Alaska ❑No estoy segura
0 Amerindia ❑Proveniente de las Islas Aleutianas ❑Otra:
Latina/Hispana ❑Nativa de Hawed
dTIENE SEGURO MEDICO PRIVADO 0 JIENE MEDICARE? DESEA QUE LE ENVIEMOS UNA CARTA
MEDICAID? ❑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)
LI Si,tengo seguro privado. U No,no tengo Medicare. ❑Si
Marque a continuation lo que sea verdadero. D En ingles
❑pero tengo un deducible alto. ❑En espanol
❑pero no cubre los examenes de detection LI No,no deseo una carts pars recordarme sabre mis
de cancer. examenes de detection.
❑No,no tengo seguro medico privado.
❑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
impuestas)pars mi grupo familiar son: que incluya a personas que no viven en su casa):
cCOMO SE 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) O Anuncio de radio
❑Medico/Personal de la clinics ❑Aviso en un periodico O Anuncio televisivo
❑Amigo/Familiar ❑Patient Navigator(programa de asistencia ❑Personal ova dude Women'sWellness Connection
❑Feria de salud para pacientes) ❑Otro:
PROPORCIONE LOS SIGUIENTES NUMEROS DONDE PODEMOS Direction postal
O COMUNICARNOS CON USTED:
uNumero de telefono de su casa particular Ciudad Estado Codigo postal
4
F-
ZNumero de telefono de su trabajo Condado
V ;
Numero de telefono celular Direction de correo electronico
Contocto de emergencia
Incluya un numero de telefono de alguien a quien podamos Ilamar si
cambiara su numero de telefono en el futuro o en casa de emergencia:
2 02
WWC— 4300 Cherry Creek Drive South, AS — Denver, Colorado 80246-1530
•
a
ment S-1-N
Women's Wellness Connection •
WWC RULES WOMEN'S WELLNESS o I,,,doo` „ p
connection ofP„blicnal}
andEnvmunrne
AGENCY# CHART# WWC#
PATIENT INSTRUCTIONS:Please read this page carefully before signing below.
LAST NAME FIRST NAME MIDDLE NAME MAIDEN NAME
LAST 4 NUMBERS OF YOUR SOCIAL SECURITY NUMBER DATE OF BIRTH AGE
I understand that by being in Women's Wellness Connection (WWC), I agree to what is written on this form.
• WWC does not pay for some tests.WWC does not pay for ANY treatment. I have talked to someone from this
clinic about what choices I have and understand that I may have to pay for some tests and treatment.
• WWC has rules about the age and income of the women that join the program. I have been honest about my
age and my income. I do not have Medicaid or Medicare Part B. I do not have other health insurance that will
pay for these tests or my health insurance has a high deductible.
• All of this information I have given to the clinic is true as far as I know. If I tell the clinic something that is not true, I
may not get these tests and I may have to pay for any tests that have already been done.
• My doctor, clinic, hospital, laboratory, and mammography center may share my information
with: (contract agency name) and the Women's Wellness Connection (WWC) a pro-
gram run by the Colorado Department of Public Health and Environment.
• If I agree to be in this program, WWC will receive my information.This may include results,costs of medical tests,
insurance, and other related information that is needed for treatment, payment, and to run this program.This
clinic and WWC may look at my health records to get this information. WWC is very careful to keep my informa-
tion private.
• WWC, who pays for the program, looks at all of the information on the women in the program to help improve
the health of women.
• I may get letters in the mail to remind me when it is time for me to go back to my doctor or clinic for tests or
treatment.
When I sign this form, I am saying that I understand what this form says and that I agree to it. I also agree
to be in this women's health program called Women's Wellness Connection.
SIGNATURE
NAME(PLEASE PRINT)
l Bf2
WWC— 4300 Cherry Creek Drive South, A5 — Denver, Colorado 80246-1530
• Bar
ment B 1 N w,
Women's Wellness Connection ale s' ,.'
WOMEN'S WELLNESS cooe„onepuvn`"
REGLAS DE WWC connection of Public yet
and Enwronment
sattailafir._. .,;,® ti emu a akw IS adatr._•.,.
AGENCY# CHART# WWC#
INSTRUCCIONES PARA EL PACIENTE:Lea esta pogina detenidamente antes de firmar a continuation.
APELLIDO PRIMER NOMBRE SEGUNDO NOMBRE APELLIDO DE SOLTERA
ULTIMOS 4 NUMEROS DE SU NUMERO DE SEGURO SOCIAL FECHA DE NACIMIENTO EDAD
Yo, entiendo que al estar en "Women's Wellness Connection" (WWC), estoy de acuerdo con lo escrito
en este formulario.
• WWC no paga por algunas pruebas.WWC no paga NINGUN tratamiento. He hablado con alguien
perteneciente a la clinica sobre las opciones que tengo y entiendo que es posible que tenga que pagar algunas
pruebas y algunos tratamientos.
• WWC tiene reglas acerca de la edad y los ingresos de las mujeres que participaron en el programa. He sido
honesta acerca de mi edad y de mis ingresos. No tengo "Medicaid" ni "Medicare" (Parte B). No tengo ningun
otro seguro medico que pagara estas pruebas, o bien mi seguro medico tiene un deducible alto.
• Toda la information que he brindado a la clinica es verdadera a mi leal saber.Si le informo a la clinica algo que no es
verdadero,es posible que no obtenga estas pruebas y que tenga que pagar las pruebas que ya me han realizado.
• Es posible que mi medico, la clinica, el hospital, el laboratorio y el centro mamografico compartan informacion
con: (nombre de la agencia) y "Women's Wellness Connection" (WWC), un
programa Ilevado a cabo por el Departamento de Medio Ambiente y Salud PGblica de Colorado.
• En caso de estar de acuerdo en participar en este programa,WWC recibira mi information.Esta information podria
incluir los resultados, los costos de las pruebas medicos,el seguro y otra information relacionada que sea necesaria
para tratamientos, pagos y para Ilevar a cabo este programa. Esta clinica y WWC pueden ver mi historial medico para
obtener esta information. WWC es muy cuidadosa en mantener mi information confidential.
• WWC, quien financia este programa, analiza toda la informacion sobre las mujeres en el programa para ayudar
a mejorar la salud de las mujeres.
• Es posible que reciba cartas por correo para recordarme cuando es el momento de regresar a mi medico o a la
clinica para que me realicen pruebas o tratamientos.
Al firmar este formulario, estoy diciendo que entiendo lo que contiene y que estoy de acuerdo con el.
Tambien estoy de acuerdo en participar en este programa de salud de mujeres Ilamado "Women's
Wellness Connection."
FIRMA
NOMBRE(EN LETRA DE IMPRENTA)
2 eft
WWC— 4300 Cherry Creek Drive South, AS — Denver, Colorado 80246-1530
MEMORANDUM
lag
' To: Office of Clerk to the Board of Weld County Commissioners
C� Date: /I pgi I ) z, a 0
COLORADO From: 1a f _OL D.e4rigel&o , Health Department
Subject: WIN G
Attached to this memo is the finalized contract, amendment to a contract, letter of renewal,
change order letter or other document as listed below.
Please sign and date below in the designated areas indicating you have received the finalized
document and return this signed memo to me in the Administration Division of the Health
Department.
Thank you for your assistance with the processing of this document.
Att. Lit
Document Name:Women s Wellness f pnncctl or4
Resolution Number: a o i l - OZ t 0
Finalized Document Received By: �£
Date Received: \ a 0 l L
Hello