HomeMy WebLinkAbout20100944.tiff RESOLUTION
RE: APPROVE AMENDMENT#1 TO 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 Amendment#1 to 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, commencing June 30, 2010, and ending June 29, 2012, with further terms and
conditions being as stated in said amendment, and
WHEREAS,after review,the Board deems it advisable to approve said amendment, 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 Amendment #1 to 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 amendment.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
the following vote on the 5th day of May, A.D., 2010.
BOARD
OF COUNTY
COLORADO
COMMISSIONERS
C
ATTEST: t =+,L .+� ✓.
1861 ro v's Radema her, C it
Wel. County Clerk to the Boar.1
O- li e
V( ;,. � �•ara Kirkmeyer, o-Tem
BY: G (C
Dep t Clerk o!the Board �� C
Sean P. ay
APP AS
William I-._Garcia
oun orney EXCUSED
David E. Long
Date of signature: S/at1io
CC : L a i 1() 2010-0944
b -/(s -1O HL0037
Memorandum
TO: Douglas Rademacher, Chair
Board of County Commissioners
' C FROM: Mark E. Wallace, MD, MPH, Director Department of Public Health and
Environment --1/4))X2 4tx-eecui,
COLORADO• DATE: April 26, 2010
SUBJECT: Women's Wellness Connection
Contract Amendment #1
Enclosed for Board review and approval is Contract Amendment #1 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 provider services is provided by both
federal and State of Colorado funding sources. The term of the amendment is June 30, 2010
through June 29, 2012.
The WWC program provides low-income, uninsured and underserved women demonstrating
lawful presence in Colorado access to timely, high-quality screening and diagnostic services to
detect breast and/or cervical cancer at the earliest stages. Weld County will be reimbursed by the
State according to current Medicare rates (see attached reimbursement fee schedule) for the
provision of these services. I recommend your approval of this amendment.
Enclosures
W
2010-0944
Attachment B-1-D
2009-2010 Women's Wellness Connection CPT Code List
This List will be updated by WWC as needed
_ CP,Viz, C Technics[
Professional
COD'E'.�� RA '�� Component•
.SLY.*_. S _.v k-_... !I::F''-!';
F
SCREENING PROCEDURES
Screening Mammogram Analog 77057 $ 79.79 $ 35.24 I $ 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 19120 $ 405.32
placement of radiologic marker
OR
I ^ Excision of breast lesion I 19125 I S 448.66
AND
Pre-op placement of needle loc wire 19290 ;.$ 150.82
Pre-op placement of needle loc wire, radiologic
interpretation and supervision 77032 $ ;58.41; $ 28.17 $ 30.24
Radiologic examination specimen 76098 $ :19.35: $ 8.15 $ 11.20
Biopsy interpretation 88305 ;$>:t7`° $ 36.69 $ 65.68
Stereotactic Core Biopsy
Breast bx, needle core, not using imaging 19100 I $ 123.56
OR
Breast bx, incisional 19101 $ 281.50
AND
Stereotactic localization, each lesion, radiologic
supervision and interpretation 77031 $ 18784'": $ 79.82 $ 108.02
Radiologic examination specimen 76098 :.$',':19� r=s $ 8.15 $ 11.20
Page i of 3
Attachment B-1-D
I Biopsy interpretation 88305 1$ l02.37': $ 36.69 I $ 65.68 I
U/S Guided Core Biopsy
Breast biopsy, percutaneous needle core, using 19102 $ 203.46
imaging guidance
AND
US Guidance for Cyst Aspiration, Radiologic 0";
76942 '.:,1.1 81 YQ 1 $ 33.80 $ 147.21
Supervision and Interpretation ,t 'r-ti{'l
Biopsy interpretation 88305 ' Q 1 $ 36.69 $ 65.68
IIIIIIIIIIIIIMN
Stereotactic Vacuum Assisted Biopsy
Automated vacuum assisted bx 19103
Tissue marker placement 19295 V84 1 _
Post procedure mammogram 770554.7,-,,,4550--- $ 35.24 $ 47.90
Stereotactic localization, each lesion, radiologic 77031 :t` '7 ' $ 79.82 $ 108.02
supervision and interpretation ,_ 5._..e�� ,:'I
P P _ n
Radiologic examination specimen 76098 ,, $ 8.15 $ 11.20
Biopsy interpretation 88305 -Y ` f $
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 $s 't4 ,e n.
Eval of FNA 88172 _ t $ 29.26 $ 21.93
Interpretation and Report of FNA 88173 $ 130.11 $ 67.39 $ 62.72
U/S Guided FNA
�::.. . , ._rt,.,.
FNA with image guidance 10022 ;, : :.- - .y
Eval of FNA 88172 1 , $ 29.26 $ 21.93
Interpretation and Report of FNA 88173 $ 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 $ 26.97
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'I block 88332 $ 39.02 $ 28.90 $ 10.12
Anesthesia for procedures 00400
Supplies& materials not usually provided 99070
CERVICAL DIAGNOSTIC PROCEDURES
Page 2 of 3
Attachment B-1-D
HPV Testing 87621 $ 51.25
•
GYN Consult 99243 $ 122.69
Colposcopy
Colposcopy without Biopsy I 57452 I $ 85.45 I
Colposcopy with Biopsy
Colposcopy with Biopsy and/or ECC 57454 $7143 46 -t; 4:`
Biopsy interpretation 88305 $ 102.37 $ 36.69 I $ 65.68
*Colposcopy with loop electrode biopsy 57460 ${ 7$i
Loop Biopsy interpretation and dissection 88307 4•1'; I '04 5fi $ 78.05 1 $ 126.97 I
*Colposcopy with loop electrode conization 57461 4imiouv,
Loop Biopsy interpretation and dissection 88307 * °e $ 78.05 I $ 126.97
Other Cervical diagnostic procedures
*Cone Biopsy
Conization of the cervix,cold knife or laser 57520v-,f
Biopsy interpretation and dissection 88307 i, ° { ; $ 78.05 1 $ 126.97 I
*Endometrial Biopsy
Endometrial sampling w/or w/out ECC 58100 - �'' s
Biopsy interpretation and dissection 88307 „,,_,.° ` $ 78.05 I $ 126.97 I
*LEEP/LOOP
Loop electrode excision ' 57522 '# 44j, :t� .q
Loop Biopsy interpretation and dissection 88307 . ,2O �' $ 78.05_ $ 126.97 I
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
Page 3 of 3
STATE OF COLORADO
Bill Ritter,Jr.,Governor woe coo
Martha E. Rudolph,Executive Director a
Dedicated to protecting and improving the health and environment of the people of Colorado
4300 Cherry Creek Dr.S. Laboratory Services Division « >,`;R) r
Denver,Colorado 80246-1530 8100 Lowry Blvd. Jan
Phone(303)692-2000 Denver,Colorado 80230-6928 Colorado Department
TDD Line(303)691-7700 (303)692-3090
Located in Glendale,Colorado of Public Health
http://www.cdphe.state.co.us and Environment
WORK STATUS CONFIRMATION LETTER
Vendor Name: Contract Routing Number:
CRS §24-30-202 requires the State Controller to approve all State Contracts. The above Amendment is not valid until it is
signed and dated below by the State Controller or delegate.Therefore,your agency is not authorized to begin performance
until you are notified that it's signed. If your agency begins performing Contract tasks prior to that date,the State of
Colorado is not obligated to pay your agency for such performance or for any goods and/or services provided prior to the date
signed.
By signing below,your confirm that(Signature MUST be that of the person signing the Contract Amendment)
a) No work has been performed under this contract
b) No work will begin under this contract until the contract is signed by the State Controller or on the effective
date,whichever is later.
� r
Signature Authorized Officer
Douglas Rademacher
Print Name of Authorized Officer
Chair, Board of Weld County Commissioners
Print Title of Authorized Officer
MAY 0 h 7019
Date Signed
RETURN THIS LETTER TO:
•
Lyndsay J. Clelland
Colorado Department of Public Health&Environment
Prevention Services Division-Women's Wellness
Connection
4300 Cherry Creek Dr So
PSD-A5-WWC
Denver CO 80246-1530
>Yr%/O-Ci y 5«f
DEPARTMENT OR AGENCY NAME
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
PSD-WWC
DEPARTMENT OR AGENCY NUMBER
FLA
CONTRACT ROUTING NUMBER
10-13404
AMENDMENT FOR TASK ORDERS#1
This Amendment is made this 01 day of April,2010,by and between the State of Colorado,acting by and through
the DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT,whose address or principal place of
business is 4300 Cherry Creek Drive South,Denver,Colorado 80246 hereinafter referred to as the"State";and,
BOARD OF COUNTY COMMISSIONERS OF WELD COUNTY,(a political subdivision of the state of
Colorado),whose address or principal place of business is 915 10th Street,Greeley,Colorado 80632-0758,for the
use and benefit of the Weld County Department of Public Health and Environment,whose address or principal place
of business is 1555 North 17`h Avenue,Greeley,Colorado 80631,hereinafter referred to as the"Contractor".
FACTUAL RECITALS
The parties entered into a Master Contract,dated January 23,2007,with contract routing number 08 FAA 00052.
Pursuant to the terms and conditions of the Master Contract,the parties entered into a Task Order Contract,dated
April 24,2009,with contract encumbrance number PO FLA WHSI0WWC,and contract routing number 09 FLA
01030,referred to herein as the"Original Task Order Contract,whereby the Contractor was to provide to the State
the following:
Breast and cervical cancer screening services and approved diagnostic services to Women's Wellness
Connection eligible women.The Contractor shall also enter a complete history in the electronic Cancer
Screening and Treatment(eCaST)database;and perform Medicaid presumptive eligibility for enrollment
in treatment under the Breast and Cervical Cancer Program as administered by Medicaid.
The State hereby exercises a"no cost"change to the specifications within the Statement of Work within the
current term of the Original Task Order Contract.
NOW THEREFORE,in consideration of their mutual promises to each other,stated below,the parties hereto agree
as follows:
1. Consideration for this Amendment to the Original Task Order Contract consists of the payments and
services that shall be made pursuant to this Amendment,and promises and agreements herein set forth.
2. It is expressly agreed to by the parties that this Amendment is supplemental to the Original Task Order
Contract,contract routing number 09 FLA 01030 referred to herein as the Original Contract,which is by
this reference incorporated herein. All terms,conditions,and provisions thereof,unless specifically
modified herein,are to apply to this Amendment as though they were expressly rewritten, incorporated,and
included herein.
3. It is expressly agreed to by the parties that the Original Task Order Contract is and shall be modified,
altered,and changed in the following respects only:
A. This Amendment is issued pursuant to paragraph 5 of the Original Task Order Contract identified
by contract routing number 09 FLA 01030. This Amendment modifies the Statement of Work
in Attachment B-1,of the Original Task Order Contract. The revised Statement of Work is
Page 1 of 3 Rev 6/25/09
incorporated by this reference and identified as Attachment B-1. The Original Task Order
Contract is modified accordingly. All other terms and conditions of the Original Task Order
Contract are reaffirmed.
4. The effective date of this Amendment is June 30,2010,or upon approval of the State Controller,or an
authorized delegate thereof,whichever is later.
5. Except for the Special Provisions and other terms and conditions of the Master Contract and the General
Provisions of the Original Task Order Contract,in the event of any conflict,inconsistency,variance,or
contradiction between the terms and provisions of this Amendment and any of the terms and provisions of
the Original Task Order Contract,the terms and provisions of this Amendment shall in all respects
supersede,govern,and control. The Special Provisions and other terms and conditions of the Master
Contract shall always control over other provisions of the Original Task Order Contract or any subsequent
amendments thereto. The representations in the Special Provisions to the Master Contract concerning the
absence of personal interest of state of Colorado employees and the certifications in the Special Provisions
relating to illegal aliens are presently reaffirmed.
6. FINANCIAL OBLIGATIONS OF THE STATE PAYABLE AFTER THE CURRENT FISCAL YEAR
ARE CONTINGENT UPON FUNDS FOR THAT PURPOSE BEING APPROPRIATED,BUDGETED,
AND OTHERWISE MADE AVAILABLE.
Page 2 of 3 Rev 6/25/09
IN WITNESS WHEREOF,the parties hereto have executed this Amendment on the day first above written.
*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:
BOARD OF COUNTY COMMISSIONERS STATE OF COLORADO
OF WELD COUNTY Bill Ritter,Jr.Governor
(a political subdivision of the state of Colorado)
for the use and benefit of the
Weld County Department of Public Health
and Environment
ke¢5 rtt.Ar By:
ignature of A thorized Officer AY 0 5 210 For the Executive Director
DEPARTMENT OF PUBLIC HEALTH
AND ENVIRONMENT
Douglas Rademacher
Print Name of Authorized Officer
Chair
Print Title of Authorized Officer
PROGRAM PPROV •
By:
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.
TATE CONTROLLER
D.vid J.McDer'i ott,CPA
By:
,
1 WELD COUNTY DEPARTMENT OF
Date: K. 6 /o P LIC HEALTH AN ENVIRONME
BY: G1A'
Mark E. Wallace, MD, MPH-Direct
Page 3 of 3 Rev 6/25/09
Attachment B-1
as modified by Contract Amendment# 1
Contract Routing# 10 FLA 13404
SCOPE OF WORK
Project Period: June 30, 2010 through June 29, 2012.
Background: The WOMEN'S WELLNESS CONNECTION (WWC) program provides low-
income, uninsured and underserved women demonstrating lawful presence in Colorado access to
timely, high-quality screening and diagnostic services to detect breast and/or cervical cancer at
the earliest stages. It is a state-run program of the National Breast and Cervical Cancer Early
Detection Program (NBCCEDP), which is administered through the Centers for Disease Control
and Prevention (CDC). Services are available across Colorado.
Direct Beneficiaries: Direct beneficiaries are women residing in Colorado who are uninsured,
underinsured, or have a high insurance deductibles; are unable to pay for breast and/or cervical
screening services; and who meet age, income and lawful presence requirements of the program.
Target populations include women of diverse ethnic backgrounds, women living in
geographically isolated and medically underserved areas, those who are rarely or never screened
for breast and/or cervical cancer, and those that may have disabilities.
Project Goals:
1. To deliver WWC services within the contractor's existing network of subcontractors.
2. To provide quality services to women receiving WWC provided screenings.
Definitions:
Breast Cancer Screen — Standard testing performed to determine the presence or non-
presence of breast cancer. Standard screening tests include a clinical breast exam (CBE)
and a mammogram.
Cervical Cancer Screen — Standard testing performed to determine the presence or non-
presence of cervical cancer. The standard screening tests are a Pap test and pelvic exam.
Core Performance Indicators—Measures of clinical quality of care and penetration of
screenings in certain target populations. Indicators are set by the Centers for Disease
Control and Prevention (CDC) and are linked to WWC federal funding received.
Contractor—Agency responsible for signing and administering this contract.
Definitive Diagnosis—The final point in cancer screening care where it is determined
whether a woman has or does not have breast or cervical cancer. This information is
usually obtained after diagnostic services have been rendered.
Diagnostic Testing — Further testing used when a definitive diagnosis is unable to be
determined by the results of prior screening tests.
eCaST—An electronic database system the WWC Program uses to track women and
Page 1 of 8
Attachment B-1
as modified by Contract Amendment#1
Contract Routing # 10 FLA 13404
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.
Subcontractor — An entity in the community that provides services for the contractor
that the contractor can not 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. Contact information must be updated annually to start work under this contract. An
Agency& Site Contact Form shall be sent to the Contractor by the State; the
Contractor must complete and submit the form by June 29, 2010 in order to start
work under this contract. A sample Agency& Site Contract Form is attached hereto
as Attachment B-1-A,incorporated herein by this reference.
i. All staff changes during the contract year must be reported to the WWC
within fifteen(15) calendar days.
b. Security access to eCaST must be renewed annually to start work under this
contract. An eCaST Renewal Form shall be sent to the Contractor by the State; the
Contractor must complete and submit the form by June 29, 2010 in order to start
work under this contract. A sample eCaST Renewal Form is attached hereto as
Attachment B-1-B, incorporated herein by this reference.
c. The Contractor must maintain a network of subcontractors and submit an updated
list of these subcontractors annually to start work under this contract. A
Subcontractor Form shall be sent to the Contractor by the State; the Contractor must
complete and submit the form by June 29, 2010 in order to start work under this
contract. A sample Subcontractor Form is attached hereto as Attachment B-1-C,
incorporated herein by this reference.
i. All subcontractor changes during the contract year must be reported to the
WWC within fifteen(15) calendar days.
2. Network:
Ensure breast and cervical cancer screening services for WWC eligible women are
performed by the contractor or through a subcontracted network of providers until a
definitive diagnosis has been achieved.
a. Subcontractors:
i 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, attached hereto as
Attachment B-1-D, incorporated herein by this reference.This list is
updated annually and will be distributed by the WWC Program. The
Contractor is responsible for communicating rate changes to
Page 2 of 8
Attachment B-1
as modified by Contract Amendment# 1
Contract Routing# 10 FLA 13404
subcontractors when they occur.
3. Specify that only services on the CPT code list will be performed and
charged to the Contractor.
4. Not be charged to WWC eligible women unless services are performed
that are not on the CPT code list. If services outside of the CPT code list
are required, arrangements for completing and paying for services
should be specified in the subcontractor agreement. Women may be
charged for services outside the CPT code list,but should be notified
before services are performed and be told how much they will cost.
5. Be agreed upon in writing through the use of a signed contract or
memorandum of understanding which includes the Period of service.
b. The Contractor must identify and support a WWC Coordinator at each screening
site(Attachment B-1-A).
i 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 an eCaST Coordinator(Attachment B-1-
B).
i The role of the data coordinator is to ensure that all information about women
screened under the WWC 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 Coordinator role and WWC Data Coordinator role may be filled
by the same person agency.
3 Enrollment:
The contractor must ensure that women screened under the WWC program:
a. Meet WWC Program Eligibility Requirements, which are attached hereto as
Attachment B-1-E, and incorporated herein by this reference.
i Eligibility guidelines may be updated during the period this scope of work is
in effect. When new eligibility guidelines are adopted for implementation by
the WWC, the Contractor will be notified and responsible for implementing
necessary changes to the Contractor workflow by a date determined by WWC.
ii Provide eligibility screenings and referrals in Spanish or other languages as
requested.
b. Meet Lawful Presence Requirements. This requirement is met for each woman by:
i Annually obtaining a signed lawful presence affidavit,a sample is attached
hereto as Attachment B-1-F, and incorporated herein by this reference and
Page 3 of 8
Attachment B-1
as modified by Contract Amendment# 1
Contract Routing# 10 FLA 13404
keeping a copy in the patient's medical record before services are rendered.
ii Annually verifying required documentation for proof of lawful presence
according to Department of Revenue guidelines:
http:/lwww.colorado.gov/cs/Satellite/Revenue-Main/XRM/1 21 62 89012 1 12.
A copy of the required documentation should be kept in the patient's medical
record and may be requested or audited by WWC at any time.
iii Document verification of lawful presence on the WWC Patient History Form
and in eCaST for each woman the contractor will be requesting
reimbursement.
1. The"Verified Legal Presence"box must be checked in the electronic
record in eCaST.
2. Failure to document in eCaST will result in non-payment of all services
rendered.
3. If documents used to verify lawful presence expire at any point during
which WWC services were provided, the contractor is responsible for
updating such documents.
4. Billing and Reimbursement:
a. The Contractor shall only request reimbursement from the WWC for a case that
meets eligibility, timeliness,performance and data requirements.
i Cases out of compliance with any of these requirements may be deemed
ineligible for payment by the WWC Program.
b. Reimbursement will be provided at the end of the case when a definitive diagnosis
has been achieved, and all data 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 woman. The WWC
Level Reimbursement Fee Structure is attached hereto as Attachment B-1-G, and
incorporated herein by this reference.
i Cases that exceed sixty(60) days in screening length 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 woman,
the same contractor will be responsible for closing the case and reaching the
point of definitive cancer diagnosis. In cases where more than one WWC
contracting agency is involved with the same woman, the contractor who
closes the case will receive all of the WWC 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:
Page 4 of 8
Attachment B-1
as modified by Contract Amendment# 1
Contract Routing# 10 FLA 13404
i Enrollment of women into the WWC Program;
ii Cancer screening services, including Pap test,pelvic exam, clinical breast
exam and mammogram;
iii Case management of abnormal findings;
iv Diagnostic services to the point of a definitive diagnosis, as necessary;
v Entry of all information into eCaST; and
vi Administrative procedures to place women with a positive diagnosis of breast
and/or cervical cancer into the Medicaid Program.
e. Data entered into eCaST is the basis for calculating reimbursement for each woman
screened.
i Data for any WWC procedure must be entered into eCaST within thirty(30)
days of 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 eCaST reports#17 - Missing Data, #10—
Procedures not Covered, and#22 -Incomplete Cases Not Yet Paid to identify
women who may have missing essential information prior to the fourteenth
(14th) of each month.
1. It is the responsibility of the Contractor to ensure its network of provider
sites has entered all required data elements prior to the WWC billing
cycle on the fourteenth(14t11)of each month.
2. Essential data elements missing from a woman's electronic record may
make the case ineligible for payment.
f One reimbursement check for all completed screenings that have met data quality
standards and occurred in the prior thirty(30) days will be sent to the Contractor
each month.
i The contractor will deal with WWC Program staff directly on non-payment of
women screened. If WWC staff is unable to rectify reimbursement,the
contractor will work with the WWC fiscal officer to the point of satisfaction
by both parties.
ii As the WWC Program budget allows, Contractors may be limited on the
number of women they can enroll and screen for the program in the fiscal
year.
5. Service Delivery:
a. The Contractor shall follow and utilize all policies and guidelines according to the
2010-2011 WWC Provider Toolkit as the standard of care when performing
services related to breast and cervical cancer screening.
i The Provider Toolkit may be updated during the period this scope of work is
in effect. When new documents/policy/guidelines or toolkit directives are
adopted for implementation by WWC agencies, the Contractor will be notified
and responsible for implementing necessary changes by a date determined by
the WWC.
b. The Contractor may utilize the WWC Nurse Consultant for clinical consultation
services on any client.
Page 5 of 8
Attachment B-1
as modified by Contract Amendment# 1
Contract Routing# 10 FLA 13404
6. Performance Standards:
a. The contractor will meet or exceed established WWC Core Performance Indicators
(Attachment B-1-H)
i. Contractors exceeding, meeting or not meeting indicators/reports will be
contacted by the WWC.
1. Contractors not meeting two or more Core Performance Indicators for a
period of six (6) months or more may be placed under a corrective action
plan.
a. This corrective action plan will have expectations set by the WWC
with time frames for completion.
b. Contractors are responsible for developing and implementing a
quality improvement plan to meet expectations.
c. Unmet expectations may result is cancellation or limitation of the
contract.
2. Contractors exceeding indicators will be recognized for good
performance.
a. The WWC reserves the right to perform regularly schedule
performance reviews.
7. Site Visits:
a. The WWC may perform site visits to select Contractors as needed. The purpose of
a WWC site visit is to provide,promote and ensure quality breast and cervical
cancer screenings in Colorado at local agencies by focusing on administrative and
management functions and clinical oversight.
b. Selection of contractors to visit is based on, but not limited to, the following:
i. WWC Core Performance Indicators;
ii. eCaST data reports, specifically Missing Data and Diagnostic Follow up
reports;
iii. Technical assistance needs;
iv. Adherence to this scope of work;
v. Participation in program trainings, conference calls and webinars; and
vi. Ability to refer positively diagnosed women to Medicaid treatment.
c. Site visits will include,but not limited to:
i. Completion of the WWC prep tool;
ii. Chart audit;
iii. Review of subcontractor agreement(s);
iv. Review of program administration and program management;
v. Review of clinical services and case management activities; and
vi. Implementation of a corrective action plan for agencies not meeting two or
more 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.
Page 6 of 8
Attachment B-1
as modified by Contract Amendment# 1
Contract Routing# 10 FLA 13404
e. Site Visits 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.
i. 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.
9. Communication:
a. When corresponding with the WWC, Contractors must use all privacy and security
measures to protect the woman's personal health information.
i. Accepted forms of communication include:
1. WWC identification number used in all email conversations
2. Mail or fax clearly marked"Confidential"
3. HIPAA compliant files transmitted via secure File Transfer Protocol
(FTP) sites.
ii. If a Contractor intends to use data from eCaST for publications,conference
presentations, and/or research projects, the Contractor must notify and receive
prior the WWC Program.
b. At least one representative from the Contractor and/or its network provider sites
must attend meetings hosted by WWC staff to ensure compliance with this contract.
i. The Contractor will attend WWC sponsored conference calls, meetings and
trainings,including but not limited to:
1. 50% of WWC monthly Health Improvement Team(HIT) calls;
2. 50% of bimonthly eCaST Users Group Conference Calls;
3. 75% of WWC quarterly clinical webinars; and
4. Other meetings and trainings upon request.
ii. WWC will attend conference calls and meetings as needed and upon special
request of the contractor.
iii. WWC will include the Contractor in all relevant program communications
that may impact the success of this contract, including:
1. Bimonthly electronic WWC Newsletter;
2. eCaST Broadcast messages;
3. Special announcements to WWC providers; and
4. Other communications.
10. Medicaid Treatment for WWC Women Diagnosed with Cancer
a. The contractor will refer women with a positive diagnosis of breast or cervical
cancer to Medicaid.
Page 7 of 8
Attachment B-1
as modified by Contract Amendment# 1
Contract Routing# 10 FLA 13404
i. Contractor personnel must follow the STEP Enrollment Process, which is
attached hereto as Attachment B-1-I, and incorporated herein by this
reference.
ii. Contractor will fax initial completed paperwork(WWC Personal History
form, WWC Rules Form, Lawful Presence affidavit and pathology report
confirming the diagnosis)to the WWC within five (5)business days of cancer
diagnosis.
iii. Women referred to Medicaid must be completely entered into eCaST within
twenty-four(24) hours of diagnosis.
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 the WWC 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.
Page 8 of 8
Weld County Health Department Contacts Form
Agency Number TBD
Agency Name: Weld County Health Department
Legal Name: Weld County Health Department
Phone: 970-304-6420 Fax: 970-304-6420
Physical Address Mailing Address
1555 N. 17th Ave. same
Greeley, CO 80631
Agency Contacts
WWC Coordinator Name: Cynthia Horn, FNP-C
Phone: 970-304-6420
Extension: 2433
Fax: 970-304-6421
Email: chorn@co.weld.co.us
eCaST Coordinator Name: Victoria Zacharko
Phone: 970-304-6420
Extension: 2471
Fax: 970-304-6421
Email: vzacharko@co.weld.co.us
Agency Director Name: Mark Wallace, MD
Phone: 970-304-6410
Extension: 2104
Fax: 970-304-6412
Email: mwallace@co.weld.co.us
Agency Contacts Form
Contract Administrator Name: Judy Nero
Phone: 970-304-6410
Extension: 2122
Fax: 970-304-6412
Email: inero@co.weld.co.us
Signature Authority Name: Board of County Commissioners of Weld County
Phone: 970-336-7204
Extension:
Fax: -970-352-0242
Email:
Fiscal Payment Coordinator Name: Wendy Paris
Phone: 970-304-6410
Extension: 2116
Fax: 970-304-6412,
Email: wparis@co.weld.co.us
Fiscal Manager Name: Judy Nero
Phone: 970-304-6410
Extension: 2122
Fax: 970-304-6412
Email: jnero@co.weld.co.us
Site Contacts Form
Agency Number: TBD
Agency Name: Weld County Health Department
Site Number: TBD
Site Name: Weld County Health Department
Phone: 970-304-6420 Fax: 970-304-6421
Physical Address Mailing Address
1555 N. 17th Ave. same
Greeley, CO 80631
Referral Phone: 970-304-6420 Extension: 2471
Site Contacts
Case Manager Name: Cynthia Horn, FNP-C
Phone: 970-304-6420
Extension: 2433
Fax: 970-304-6421
Email: chorn@co.weld.co.us
Clinician Name: Cynthia Horn, FNP-C
Phone: 970-304-6420
Extension: 2433
Fax: 970-304-6421
Attachment B-1-A
WWC Contacts Descriptions Fiscal Year 2010-2011
Please read the descriptions below and determine the person or persons who fill each role at your
agency and clinic(s). Please note that agency staff may fill more than one role.
Agency/Administrative Contacts
WWC Coordinator
• One per agency
• Serves as the "point person" for WWC at the agency by overseeing WWC activities and ensuring
that quality and timely patient care are provided
• Serves as the liaison between the WWC state staff and the agency staff
• Is likely to receive any communication from WWC and knows how to disseminate it at the
agency
• Knows all the WWC roles within the agency and who is assigned to each
• Attends monthly Health Improvement Team (HIT) calls
• Is responsible for ensuring that subcontractor contracts are in place
• Is responsible for all communications with subcontractors
• May supervise the case managers
• Must have eCaST access
• Coordinates WWC training for new and existing staff
• May be contacted by ACS Referral Line Call Center staff, WWC Screening Navigators, or WWC
staff when a woman is experiencing breast or cervical cancer symptoms and she needs an
appointment more urgently than through the regular referral line
eCaST Coordinator
• One per agency
• This person is responsible for eCaST activity including quality and timeliness of data entry
• Responsible for annual renewals
• Assures new users are added to eCaST and receive appropriate eCaST training
• Attends eCaST Users Group meetings
• Determines who responds to data errors
• Must have eCaST access
• Receives and coordinates agency response to the duplicates fax, data error reports and MDE
edit requests from WWC state staff
Agency Director
• One per agency
• This is the highest level person at the agency who is aware of WWC activities and influences
overall program operations
Page4of6
Attachment B-1-A
WWC Contacts Descriptions Fiscal Year 2010-2011
• May receive communication from WWC Program Director and Program Manager
Contract Administrator
• Person(s) responsible for processing of WWC contracts
• Ensures signatures are included and all requested documents are sent to the WWC contracts
management and fiscal teams,as required
• Receives communication from WWC fiscal and contracts management teams
Signature Authority
• Person(s) with the power to sign grant contracts for the agency
Fiscal Payment Coordinator
• One per agency
• Point person for fiscal activity for WWC fiscal activity at the agency
• Receives monthly Grant Activity Statement
• Receives the reimbursement checks from WWC and may be responsible for reconciliation of
payments
• May submit WWC fiscal reports
• Has access to eCaST (optional but preferred)
Fiscal Manager
• Responsible for overall fiscal operations at the agency
• This is the highest level person at the agency who is aware of WWC fiscal activities and
influences the overall program budget
• May receive communication from WWC Program Director or WWC Fiscal Manager
Page 5 of 6
Attachment B- -A
WWC Contacts Descriptions Fiscal Year 2010-2011
Site/Clinic Contacts
Case Manager
• At least one per site
• Ensures that women with abnormal screening results, or a diagnosis of cancer, receive
appropriate diagnostic and /or treatment services in a timely manner.
• Has a direct relationship with clients and may provide patient education and/or communication
• Works closely with clinicians
• Works closely with WWC Nurse Consultant to ensure proper BCCP enrollment
• Must have access to eCaST
Clinician
• At least one per site
• Must be: MD, NP, PA
• Provides CBE, Pap test and pelvic exam for patients
• Ultimately responsible for quality and timeliness of care
• May supervise case managers
Page 6 of 6
WOMEN'S WELLNESS
connection
eCaST RENEWAL FORM
WWC/eCaST Coordinator: Cynthia Horn, FNP-C
Agency: Weld County Health Department
Re: Secure External User Id Annual Renewal
From: Dee Thomas, Data Specialist Phone: (303) 692-2436
Date: Fax: (303) 758-3268
In accordance with the Colorado Department of Public Health and Environment Policy Manual's Access Contro
policy, all authorized state database users are required to periodically renew their security access forms. The
names of the staff at your agency that currently have eCaST access are listed below. Please have each staff
member sign and date where indicated to continue accessing eCaST. A program manager's signature is also
required where indicated. Be advised that a missing signature on this form will indicate that the employee no
longer requires eCaST access in which case his or her access will be terminated immediately. Please complete
and return this form by 6/29/10, to the contact shown below. Thank you in advance for your prompt attention.
Employee Name Employee Signature Date
C� I
ynq Ili G NCVri ki770 e- <I 2'7-70
- — 762 •
VI CID ct la cG i ck r Igo Gler
We nett, hats Li- z -7-Th
Program Manager or Supervisor /�h /a <� �ct , � �«�� e v, - 27-/0 _.
Print Name Signature Date
Contact: Dee Thomas, fax 303-758-3268.
If you have any questions or comments, please contact me at 303-692-2436 or dolores.thonrts%nstate.co.os, or
my supervisor, Rachel Foster, at 303-692-251 I or rachel.foster iistataco.us.
Subcontractor Form
Agency Name: Weld County Health Department
Subcontractors:
Please provide information for each of your subcontractors. If you work with more than four
subcontractors, please make copies of this form.
Name: Surgical Associates of Greeley
Address: 1800 15th Street, Suite 210
City: Greeley Zip: 80631
Sites working with this subcontractor:
All
Name: Labcorp Laboratory Corporation of America
Address: 6665 South Kenton Street, Suite 210
City: Englewood Zip: 80111
Sites working with this subcontractor:
All
Name: North Colorado Medical Center
Address: PO Box 1988
City: Greeley Zip: 80632
Sites working with this subcontractor:
All
Name: Banner Imaging Association
Address: PO Box 29315
City: Phoenix Zip: 85038
Sites working with this subcontractor:
All
Name: Summit Pathology
Address: PO Box 30309
City: Charleston Zip: 29417
Sites working with this subcontractor:
All
Attachment B-1-D
2009-2010 Women's Wellness Connection CPT Code List
This List will be updated by WWC as needed
"f �k M �'� ,,yam � z� K�'r.�'�' ,r t�a t�r ir'f�a`+•e }5��tr t{ ,� .': _
w •
,
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 19120 $ 405.32
placement of radiologic marker
OR
Excision of breast lesion I 19125 1 $ 448.66
AND
Pre-op placement of needle loc wire 19290 'Z$1,,5.0.'8_,,
Pre-op placement of needle loc wire, radiologic f �t 28.17 $ 30.24
77032 $ 5 4 $
interpretation and supervision
Radiologic examination specimen 76098 _ r3 $ 8.15 $ 11.20
Biopsy interpretation 88305 ��$��?t �� $ 36.69 $ 65.68
Stereotactic Core Biopsy
I Breast bx, needle core, not using imaging I 19100 I $ 123.56 I
OR
I Breast bx, incisional I 19101 I $ 281.50
AND
Stereotactic localization, each lesion,radiologic 77031 {1$7 84 = $ 79.82 $ 108.02
supervision and interpretation
Radiologic examination specimen 76098 . $_; 0: $ 8.15 $ 11.20
Page 1 of 3
Attachment B-1-D
Biopsy interpretation 88305 $.1t)2 3T $ 36.69 I $ 65.68
U/S Guided Core Biopsy
Breast biopsy, percutaneous needle core, using 19102 $ 203.46
imaging guidance
AND
US Guidance for Cyst Aspiration, Radiologic .$ ''`
7 76942 . .,=1$' .iii,r4 $ 33.80 $ 147.21
Supervision and Interpretation
Biopsy interpretation 88305 =.k$':4.1'02„; r $ 36.69 $ 65.68
Stereotactic Vacuum Assisted Biopsy
Automated vacuum assisted bx 19103 $ 512 S3;``i
Tissue marker placement 19295
Post procedure mammogram 77055 „$314, $ 35.24 $ 47.90
Stereotactic localization, each lesion, radiologic
supervision and interpretation 77031 x$ 8 7 $ 79.82 $ 108.02
Radiologic examination specimen 76098 , z' " $ 8.15 $ 11.20
Biopsy interpretation 88305 3 $ 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 imageguidance 10021 °ii_ 'I25'Q
Eval of FNA 88172 =.4.4*AtiC $ 29.26 $ 21.93
Interpretation and Report of FNA 88173 $ 130.11 $ 67.39 $ 62.72
U/S Guided FNA
FNA with image guidance 10022 irsS; 1,V
Eval of FNA 88172ilt, �= $ 29.26 $ 21.93
Interpretation and Report of FNA 88173 ;I Oi $ 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 $ 26.97 I
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'I block 88332 $ 39.02 $ 28.90 $ 10.12
Anesthesia for procedures 00400
Supplies& materials not usually provided 99070
CERVICAL DIAGNOSTIC PROCEDURES
Page 2 of 3
Attachment B-1-D
HPV Testing 87621 $ 51.25
GYN Consult 99243 $ 122.69
Colposcopy
Colposcopy without Biopsy 57452 $ 85.45
Colposcopy with Biopsy
Colposcopy with Biopsy and/or ECC 57454 7:,.$;' 1,43A6' ':,-;',.
Biopsy interpretation 88305 $ 102.37 $ 36.69 I $ 65.68
*Colposcopy with loop electrode biopsy
Loop Biopsy interpretation and dissection 88307 TiV,A001,203K $ 78.05 I $ 126.97 I
*Colposcopy with loop electrode conization _ 57461 410*
Loop Biopsy interpretation and dissection 88307 i;.1:'- `b.2 g $ 78.05 I $ 126.97 I
Other Cervical diagnostic procedures
*Cone Biopsy
Conization of the cervix, cold knife or laser 57520 :4 $40VM
Biopsy interpretation and dissection 88307 ass" i?-V, $ 78.05 I $ 126.97 I
*Endometrial Biopsy
Endometrial sampling w/or w/out ECC 58100 4,3 {{Q2
Biopsy interpretation and dissection 88307 t, D ;., . • $ 78.05 I $ 126.97 I
*LEEP/LOOP
Loop electrode excision
Loop Biopsy interpretation and dissection 88307 ii4:0).0,214: $ 78.05_I $ 126.97 I
57522
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
Page 3 of 3
Attachment B-1-E
WOMEN'S WELLNESS CONNECTION 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
Persons in family 250%of DHHS FEDERAL POVERTY
(Household) GUIDELINES(FPL)
Size Monthly Annual
1 $2,256 $27,075
2 $3,035 $36,425
3 $3,815 $45,775
4 $4,594 $55,125
5 $5,373 $64,475
6 $6,152 $73,825
7 $6,931 $83,175
8 $7,710 $92,525
• Lack of 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(1-551)
o Other forms of ID are also acceptable,please see:
http:."www.colorado.gov/cs/Satcll itc-Revenue-Mai»/XRM/1216289012125
• Have not had a mammogram for 12 months or more unless currently experiencing symptoms*
• Have not had a Pap test for 12 months(if using conventional Pap smears) or 22 months(if using
liquid based technology) or more unless currently experience symptoms. Women are eligible for
a pelvic exam every year*
*Breast and cervical cancer screenings may be provided separately if clinically appropriate
Page 1 of 1
Attachment B-1-F
Women's Wellness Connection Legal Presence Affidavit-English
(Copy on 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:
Page 1 of 2
Attachment B-1-F
Women's Wellness Connection Legal Presence Affidavit- Spanish
(Copy on agency letterhead)
Verificacion de presencia legal DECLARACION
Yo, , afirmo bajo
juramento y pena de perjurio que de conformidad con las leyes del estado de Colorado (marque
una de las opciones siguientes):
Soy ciudadano(a) de los Estados Unidos, o
— Soy residente permanente en los Estados Unidos, o
- Mi presencia en los Estados Unidos es legal de conformidad con las leyes federales.
Entiendo que para dar cumplimiento a la ley, esta declaracion bajo juramento es necesaria pars
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 declaracion 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:
Page 2 of 2
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 or pelvic are normal and abnormal and abnormal, requiring
exam only. Result require no further require further non- additional invasive
is normal and action. Enrollment invasive diagnostic diagnostic testing.
requires no further and data entry fee testing. The The definitive
action. added. definitive diagnosis diagnosis may be
is non-cancerous. cancer or non-
Case management cancer. An
fee added. additional case
management fee
The cervical level added.
includes paid HPV
testing and/or a
gynecological
consult that closes
the case.
BREAST $75 $190 $505 $1405
CANCER
SCREEN
Reimbursement
CERVICAL $75 $135 $175 $650
CANCER
SCREEN
Reimbursement
Page 1 of 1
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Attachment B-I-I
WOMEN'S WELLNESS
G
Connect. Gel checked. Be well.
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.
STE' 1 — C•nfirm Eli•i•ilityf•r =CC' ; C•m•I t eCaST t Entry
The provider site must confirm that the woman was eligible for Women's Wellness Connection
and that her diagnosis was made using WWC funds.
Eligibility criteria include:
❑ 40-64 years of age
❑ At or below the 250% Federal Poverty Level
❑ Meets identity and citizenship verification criteria (as stated in the Colorado
Department of Revenue"Rules for Evidence of Lawful Presence" at
http://www.colorado.gov/cs/Satellite/Reven ue-Main/XRM/1216289012524)
❑ Does not have health insurance or has health insurance that will not cover breast or
cervical cancer treatment.
STOP
' The BCCP enrollment process cannot proceed until all data is entered into eCaST.
STEP 2— Determine Whether the Diagnosis is Eligible for BCCP
The list of eligible diagnoses can be found online at:
http://www.cdphe.state.co.us/PP/cwcci/BCCPEliqibilityChart.pdf
STOP
If your pathology report has a diagnosis that is NOT on this list, please consult with
WWC Nurse Consultant at 303-692-2323 before deciding not to proceed.
RF:3-10 Page 1 of4
Attachment B-1-I
STEP 3- Obtain Approval from WWC
Fax ONLY 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)
❑ Signed lawful presence affidavit.
STOP
Eligibility must be confirmed by WWC staff BEFORE you call the PE Hotline. A
WWC staff person will notify you within three (3) business days of receipt to confirm eligibility
of the woman.
STEP 4— Obtain Presumptive Eligibility PE Number in BCCP
STOP
Do not attempt to get the PE number for the client until you have received approval
from WWC. Clients should not be scheduled for surgery, radiological testing or treatment until
you have received the PE number for the client.
o 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.
o 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:
http://www.Colorado.qov/cs/Satellite?blobcol=urldata&blobheader=application%2 Fpdf&blobke
y=id&blobtable=MungoBlobs&blobwhere=1225954419780&ssbinary=true (English)
http://www.Colorado.qov/cs/Satellite?blobcol=urldata&blobheader=application°/u2Fpdf&blobke
y=id&blobtable=MungoBlobs&blobwhere=1228626242862&ssbinary=true (Spanish)
RF: 3-10 Page 2 of 4
Attachment B-1-I
Clients should bring proof of income and legal presence.
After you help the client complete this application in your office:
o Please fax copies of the following forms to the WWC Nurse Consultant (303-758-
3268):
o The signature page of the full application—this is the last page
o The completed PE form
• Please be sure to complete the box in the left lower corner of the PE
form with the information received from the PE Hotline attendant.
• http://www.cdphe.state.co.us/PP/cwcci/PEForm.pdf(English)
• http://www.cdphe.state.co.us/PP/cwcci/PEFormSpanish.pdf(Spanish)
o Submit the completed,full application to your County Department of Human/Social
Services office within five business days of receiving the PE number. For a listing of
these offices, see: http://www.cdhs.state.co.us/servicebvcountv.htm
o If you submit the full Medicaid application by fax, please use the "Fax Cover Sheet for
Medicaid Applications." This will alert the staff at your county Human/Social Service
office that this is a BCCP Medicaid application and facilitate processing. This can be
found at:
http://www.cdphe.state.co.us/PP/cwcci/forms/FaxcoversheetforMedicaidApP.pdf
o Keep a copy of the fax confirmation sheet, the person's name that the application was
sent to and original Medicaid application in the client's chart.
STOP
If this step is not completed correctly, the woman will be dropped from Medicaid
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.orq. 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.
RF:3-10 Page 3 of
Attachment B-I-I
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.
RF: 3-10 Page 4 of 4 •
<Insert Entity's Letterhead>
Signature Authority Letter
(insert name of entity) exists as a (insert type of entity, i.e. non-profit corporate
entity) and as such does not have a President or Vice-President, but instead is governed
by a Board of Directors. In addition, (insert name of entity) operates under the
leadership of(insert name of individual signing the contract), our Executive Director.
(insert name of individual signing the contract) has the authority to sign contracts on
behalf of(insert name of entity) which are binding
Signature
Print Name
Board President
Title
Date
STATE OF COLORADO
Bill Ritter,Jr.,Governor ---
Martha E. Rudolph,Executive Director -.o4•co\�\
Dedicated to protecting and improving the health and environment of the people of Colorado yam%rs � ,:�)
4300 Cherry Creek Dr.S. Laboratory Services Division \*
Denver,Colorado 80246-1530 8100 Lowry Blvd. \ 1816 T/
Phone(303)692-2000 Denver,Colorado 80230-6928 ---
TDD Line(303)691-7700 (303)692-3090 Colorado Department
Located in Glendale,Colorado of Public Health
http://www.cdphe.state.co.us and Environment
June 7, 2010
Judy Nero
Weld County Dept of Public Health & Environment
Greeley, Colorado 80631
Dear Ms. Nero:
Enclosed is a fully executed contract amendment signed 6 /6/10, Routing No. 10 FLA 13404, for the
Women's Wellness Connection Breast and Cervical Cancer Screening Program. Work may begin on
6/30/10 under this amendment.
Please feel free to contact me at(303) 692-2524 with any questions.
Respectfully,
L say��L say J. Cl and, MS
PSD Contracts
Enc.
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