HomeMy WebLinkAbout20052493.tiff RESOLUTION
RE: APPROVE CHILD PROTECTION AGREEMENT FOR SERVICES AND AUTHORIZE
CHAIR TO SIGN -WESTERN PATHOLOGY CONSULTANTS, INC. (WPCI) MAYFIELD
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 Child Protection Agreement for Services
between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Social Services, and Western
Pathology Consultants, Inc. (WPCI) Mayfield, commencing June 1, 2005, and ending May 31,
2006, with further terms and conditions being as stated in said agreement, and
WHEREAS,after review, the Board deems it advisable to approve said agreement, a copy
of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, ex-officio Board of Social Services, that the Child Protection Agreement for
Services between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Social Services, and Western
Pathology Consultants, Inc. (WPCI) Mayfield be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to
sign said agreement.
The above and foregoing Resolution was, on motion duly made and seconded, adopted by
lowing vote on the 22nd day of August, A.D., 2005, nunc pro tunc June 1, 2005.
•.
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BOARD OF COUNTY COMMISSIONERS
�j(f' ' \. WELD COUNTY, COLORADO
in! \ r. '�y1 �k��YG �' ✓ 'L�""".v'( �,
ATTEST,
�s7 - '/i / William . Jerke, Chair
�,'\j]��/ d,,C y Clerk to the Board
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BY: 7/ � ile, o-Tem
Deputy Clerk to the Board
David . n
AP AS .•
Robert-J. Masd
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Date of signature: _/�1LC-5
2005-2493
SS0032
CO ` S5 C 3/-0S-
H"......... DEPARTMENT OF SOCIAL SERVICES
rs
P.O. BOX A
GREELEY, CO. 80632
Website: www.co.weld.co.us
' Administration and Public Assistance(970)352-1551
Child Support(970)352-6933
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•
COLORADO MEMORANDUM
TO: William Fl. Jerke, Chair Date: August 17, 2005
Board of County Commissioners
FR: Judy A. Griego, Director, Social Services C (tilt
�
74,14,11
RE: Child Protection Agreement for Services beeen the Weld County
Department of Social Services and Western Pathology Consultants, Inc. Mayfield
Enclosed for Board approval is a Child Protection Agreement for Services between the Weld
County Department of Social Services (Department) and Western Pathology Consultants, Inc.
Mayfield(WPCl/Mayfield). This contract was reviewed at the Board's Work Session held on
May 31, 2005.
The major provisions of the contract are as follows:
1. The term of the contract is June 1, 2005 through May 31, 2006.
2. The source of funding is Child Welfare Administration funding.
3. WPC/Mayfield will provide monitored sobriety services at the Greeley and the South
County facility for families and adolescents involved in the child welfare system.
4. The Department will reimburse WPCUMayfreld according to their fee schedule for a total
not to exceed $30,000.
If you have any questions,please telephone me at extension 6510.
2005-2493
Contract Number 05-06-CPS-53
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF SOCIAL SERVICES
AND WPCl/MAYFIELD
This Agreement,made and entered into the day of June 2005,by and between the Board of Weld
County Commissioners,sitting as the Board of Social Services,on behalf of the Weld County Department of Social
Services,hereinafter referred to as"Social Services,"and Western Pathology Consultants,Inc. (WPCI)Mayfield,
hereinafter referred to as"WPCl/Mayfield."
WITNESSETH
WHEREAS,required approval,clearance,and coordination have been accomplished from and with
appropriate agencies;and
WHEREAS,the Colorado Department of Human Services has provided Child Welfare Regular
Administration funding to Social Services for immediate referrals for monitored sobriety services for families,
children,and adolescents; and
WHEREAS, Social Services requires the services of a substance abuse testing and screening provider to
assist the County to deliver services for referrals for monitored sobriety to child welfare clients, and WPCl/Mayfield
is willing and able to provide such services;and
WHEREAS,WPCl/Mayfield is a Colorado non-profit organization organized for the purpose of alcohol
and drug test screening.
NOW THEREFORE, in consideration of the premises,the parties hereto covenant and agree as follows:
1. Term
This Agreement shall become effective on June 1,2005,upon proper execution of this Agreement and
shall expire May 31,2006,unless sooner terminated as provided herein.
2. Scope of Services
Services shall be provided by WPCl/Mayfield network providers to any person(s)eligible for child
protection services in compliance with Exhibit A"Scope of Services,"a copy of which is attached by
reference.
3. Payment
a. Payment shall be made on the basis of Exhibit B,"Payment Schedule,"and Exhibit C,"Fee
Schedule,"copies of which are attached hereto and incorporated herein by reference.
"Payment Schedule"shall establish the maximum reimbursement,which will be paid from Child
Welfare Regular Administration funds during the duration of this Agreement.
WPCl/Mayfield, in accordance with federal HIPAA regulations,has adopted the standard
transaction code set for all treatment services on or before October 16,2003. Even though this
compliance has changed the service labels and groupings,the net fees associated with those
services have not changed.
b. WPCl/Mayfield shall submit an itemized monthly bill to Social Services for all costs incurred and
services provided pursuant to Exhibit A of this Agreement in accordance with criteria established
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Contract Number 05-06-CPS-53
by Social Services. WPCl/Mayfield shall submit all itemized monthly billings to Social Services
no later than the twenty-fifth(25)day of the month following the month the cost was incurred.
c. Payments of costs incurred pursuant to this Agreement is expressly contingent upon the
availability of Child Welfare Regular Administration funds to Social Services.
d. Social Services shall not be billed for,and reimbursement shall not be made for time involved in
activities outside of those defined in Exhibit A. Work performed prior to the execution of this
Contract shall not be reimbursed or considered part of this Agreement.
4. Financial Management
At all times from the effective date of this Contract until completion of this Contract,WPCI/Mayfield shall
comply with the administrative requirements,cost principles and other requirements set forth in the
Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds
expended under Child Welfare Regular Administration funding must conform to the Single Audit Act of
1984 and OMB Circular A-133.
5. Payment Method
Unless otherwise provided in the Scope of Services and Payment Schedule:
a. WPCUMayfield shall provide proper monthly invoices and itemization of services performed for
costs incurred in the performance of the agreement.
b. Social Services may withhold any payment if WPCI/Mayfield has failed to comply with the
Financial Management Requirements,program objectives,contractual terms,or reporting
requirements. In the event of a forfeiture of reimbursements,WPCUMayfield may appeal such
circumstance to the Director of Social Services. The decision of the Director of Social Services
shall be final.
6. Assurances
WPCI/Mayfield shall abide by all assurances as set forth in the attached Exhibit D,which is attached hereto
and incorporated herein by reference.
7. Compliance with Applicable Laws
At all times during the performance of this contract,Mayfield shall strictly adhere to all applicable
federal and state laws,orders,and all applicable standards,regulations,interpretations or guidelines issued
pursuant thereto. This includes the protection of the confidentiality of all applicant/recipient records,
papers,documents,tapes and any other materials that have been or may hereafter be established which
relate to the Contract. WPCUMayfield acknowledges that the following laws are included:
- Title VI of the Civil Rights Act of 1964,42 U.S.C. Sections 2000d—1 et.seq.and its implementing
regulation,45 C.F.R.Part 80 et seq.;and
- Section 504 of the Rehabilitation Act of 1973,29 U.S.C.Section 794,and
- its implementing regulations,45 C.F.R.Part 84;and
- the Age Discrimination Act of 1975,42 U.S.C.Sections 6101 et.seq.and
its implementation regulations,45 C.F.R.Part 91;and
- Tide VII of the Civil Rights Act of 1964;and
- the Age Discrimination in Employment Act of 1967;and
- the Equal Pay Act of 1963;and
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Contract Number 05-06-CPS-53
- the Education Amendments of 1972;and
- Immigration Reform and Control Act of 1986,P.L.99-603;
42 C.F.R.Part 2
and all regulations applicable to these laws prohibiting discrimination because of race,color,
National origin,and sex,religion and handicap,including Acquired Immune Deficiency Syndrome(AIDS)
or AIDS related conditions,covered under Section 504 of the Rehabilitation Act of 1973,as amended,
cited above. If necessary,WPCI/Mayfield and Social Services will resist in judicial proceedings any
efforts to obtain access to client records except as permitted by 42 CFR Part 2.
Included is 45 C.F.R.Part 74 Appendix G 9,which requires that affirmative steps be taken to assure that
small and minority businesses are utilized,when possible,as sources of supplies,equipment,construction
and services. This assurance is given in consideration of and for the purpose of obtaining any and all
federal and/or state financial assistance.
Any person who feels that s/he has been discriminated against has the right to file a complaint either with
the Colorado Department of Human Services or with the U.S.Department of Health and Human Services,
Office for Civil Rights.
8. Certifications
WPCI/Mayfield certifies that,at the time of entering into this Contract, it has currently in effect all
necessary licenses,approvals,insurance,etc.required to properly provide the services and/or supplies
covered by this contract.
9. Monitoring and Evaluation
WPCUMayfield and Social Services agree that monitoring and evaluation of the performance of this
Agreement shall be conducted by WPCI/Mayfield and Social Services. The results of the monitoring and
evaluation shall be provided to the Board of Weld County Commissioners and Mayfield.
WPCI/Mayfield shall permit Social Services,and any other duly authorized agent or governmental agency,
to monitor all activities conducted by WPCUMayfield pursuant to the terms of this Agreement. As the
monitoring agency may in its sole discretion deem necessary or appropriate,such program data,special
analyses,on-site checking, formal audit examinations,or any other reasonable procedures. All such
monitoring shall be performed in a manner that will not unduly interfere with agreement work.
10. Modification of Agreement
All modifications to this agreement shall be in writing and signed by both parties.
11. Remedies
The Director of Social Services or designee may exercise the following remedial actions should s/he find
WPCl/Mayfield substantially failed to satisfy the scope of work found in this Agreement. Substantial
failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by
Mayfield. These remedial actions are as follows:
a. Withhold payment to WPCUMayfield until the necessary services or corrections in performance are
satisfactorily completed;
b. Deny payment or recover reimbursement for those services or deliverables,which have not been
performed and which due to circumstances caused by WPCl/Mayfield cannot be performed or if
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Contract Number 05-06-CPS-53
performed would be of no value to the Social Services. Denial of the amount of payment shall be
reasonably related to the amount of work or deliverables lost to Social Services;
c. Incorrect payment to WPCl/Mayfield due to omission,error,fraud,and/or defalcation shall be
recovered from WPCl/Mayfield by deduction from subsequent payments under this Agreement or
other agreements between Social Services and Mayfield,or by Social Services as a debt due to Social
Services or otherwise as provided by law.
12. Representatives
For the purpose of this Agreement,the individuals identified below are hereby designated representatives
of the respective parties. Either party may from time to time designate in writing a new or substitute
representative(s):
For Social Services:
Gloria Romansik Social Services Administrator
Name Title
For Mayfield:
Misty West Chief Operations Manager
Name Title
13. Notice
All notices required to be given by the parties hereunder shall be given by certified or registered mail to the
individuals at the addresses set forth below. Either party may from time to time designate in writing a
substitute person(s)or address to whom such notices shall be sent:
To: Social Services To: WPCl/Mayfield
Judy A.Griego,Director Misty West
P.O.Box A P.O.Box 1936
Greeley,CO 80632 Scottsbluff,NE 69361
14. Litigation
WPCl/Mayfield shall promptly notify Social Services in the event that WPCl/Mayfield learns of any actual
litigation in which it is a party defendant in a case that involves services provided under this Agreement.
Mayfield,within five(5)calendar days after being served with a summons,complaint,or other pleading
which has been filed in any federal or state court or administrative agency, shall deliver copies of such
document(s)to the Social Services Director. The term"litigation"includes an assignment for the benefit
of creditors,and filings in bankruptcy,reorganization and/or foreclosure.
15. Termination
This Agreement may be terminated at any time by either party given thirty(30)days written notice and is
subject to the availability of funding. WPCl/Mayfteld reserves the right to suspend services to clients if
funding is no longer available.
16. Entire Agreement
This Agreement,together with all attachments hereto,constitutes the entire understanding between the
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Contract Number 05-06-CPS-53
parties with respect to the subject matter hereof,and may not be changed or modified except as stated in
Paragraph 10 herein.
4001, 'WITNESS WHEREOF,the parties hereto haveeduly executed the Agreement as of the day,month,and year first
,,��, I . /_ .0`written. /ate/at/2A
1861 ta_ ,3lki OUNTY BOARD OF COUNTY
%iu`� Mt TO THE BOARD COMMISSIONERS WELD
r Fr COUNTY,COLORADO/``....„ .0) : /!L!J"/t/ _ ,p1e/ '/� By: ! �✓''
Deputy Clerk / .- --- William H.Jerke,Chair AUG 2 2 2005
AP D AS TO FO WPCUMAYFIELD
4���j _ BY 5-3/-031
CoGn[y Att6rtfey Misty We Chief Operations Manager
LD COUNTY DEPARTMENT
OF SOCIAL SERVICES
By:
J A.G go,Direct r
Page 5 of 17
07005- - 0,9419,
Contract Number 05-06-CPS-53
EXHIBIT A
SCOPE OF SERVICES
Special Conditions:
A. WPCI/Mayfield will conduct monitored sobriety for Social Services' clients at the Weld County
Department of Social Services,Annex building in Greeley and the South County Office in Del
Camino.
B. WPCI/Mayfield will confirm any positive and negative monitored sobriety results within 24 hours
through a phone call and a fax to the Social Services caseworker.
C. WPCI/Mayfield will use the Instant Drug Screen (drugs plus adulteration check)and the Saliva
Test(alcohol only)with Social Service clients.
D. WPCI/Mayfield will provide a qualified monitored sobriety collector on site three days a week at
the Department of Social Services from 3:00 p.m.-7:00 p.m.,or as modified by Social Services.
E. Internet result access;24 hours a day 7 days per week through Norchem Website.
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Contract Number 05-06-CPS-53
EXHIBIT B
PAYMENT SCHEDULE
1. Funding and Method of Payment
Social Services agrees to reimburse to WPCl/Mayfield in consideration for the work and services
performed,a total amount not to exceed Thirty Thousand Dollars($30,000.00)under Child Welfare
Regular Administration funding.
Expenses incurred by Mayfield,in association with said project prior to the term of this agreement,are not
eligible Social Services expenditures and shall not be reimbursed by Social Services.
Payment pursuant to this Contract,if Child Welfare Regular Administration funds,whether in whole or in
part,is subject to and contingent upon the continuing availability of Child Welfare Regular Administration
funds for the purposes hereof. In the event that said funds,or any part thereof,become unavailable as
determined by Social Services,Social Services may immediately terminate this Contract or amend it
accordingly.
2. Fees for Services—as shown on the attached Exhibit C"Fee Schedule."
Social Services referrals will not be sent to collections by WPCI/Mayfield for default of co-pay/fees.
Services will be performed regardless of client's refusal or inability to pay co-pay.
WPCI/Mayfield will collect any applicable sliding scale co-pays and credit Social Services for any
payments received on the monthly billing statements.
3. Submittal of Vouchers
WPCl/Mayfield shall prepare and submit monthly the itemized voucher according to the criteria listed
under"Standards of Responsibility"in Exhibit E,and certify that the services authorized were provided on
the date indicated and the charges made were pursuant to the terms and conditions of Exhibit A.
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Contract Number 05-06-CPS-53
EXHIBIT C
COLLECTION FEES
Description of Services Charge
Instant 5 panel Drug Screen-Tests for: $12.00
THC, COC, AMP, OPIATES, PCP
Instant 5 panel sent to lab for confirmation using a
chemically unrelated method. $25.00
Standard Laboratory Test- Tests for:
ALC, AMP/METH, BENZ, COC, OPI, PCP, THC $12.00
Club Drug Panel-Tests for:
ECSTASY, GHB, KETAMINE, OXYCODONE $48.50
Hair Test: Tests for:
THC, COC, OPIATES, PCP, AMP $90.00
Breathalyzer Screening $2.00
Breathalyzer Confirmation if screening test was POS $2.00
WPCI- Court Testimony $75.00 per hour
SWAB
Instant Oral Fluid $32.00
Lab based Oral Fluid $37.50
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Contract Number 05-06-CPS-53
EXHIBIT D
ASSURANCES
1. WPCI/Mayfield agrees it is an independent contractor and that its officers and employees do not become
employees of Weld County,nor are they entitled to any employee benefits as Weld County employees,as
the result of the execution of this Agreement.
2. Weld County,the Board of County Commissioners of Weld County, its officers and employees,shall not
be held liable for injuries or damages caused by any negligent acts or omissions of Mayfield-contracted
providers or its employees,volunteers,or agents while performing duties as described in this Agreement.
WPCI/Mayfield shall indemnify,defend,and hold harmless Weld County,the Board of County
Commissioners of Weld County,its employees,volunteers,and agents. WPCUMayfield shall provide
adequate liability and worker's compensation insurance for all its employees,volunteers,and agents
engaged in the performance of the Agreement upon request,WPCUMayfield shall provide Social Services
with the acceptable evidence that such coverage is in effect.
3. No portion of this Contract shall be deemed to constitute a waiver of any immunities the parties or their
officers or employees may possess,not shall any portion of this Agreement be deemed to have treated a
duty of care with respect to any persons not a party of this Agreement.
4. No portion of this Contract shall be deemed to create an obligation on the part of the County of Weld, State
of Colorado,to expend funds not otherwise appropriated in each succeeding year.
5. If any section, subsections,paragraph,sentence,clause,or phrase of this Contract is for any reason held or
decided to be unconstitutional,such decision shall not affect the validity of the remaining portions. The
parties hereto declare that they would have entered into this Contract and each and every section,
subsection,paragraph, sentence,clause,and phrase thereof irrespective of the fact that any one or more
sections,subsections,paragraphs, sentences,clauses,or phrases might be declared to be unconstitutional or
invalid.
6. No officer,member or employee of Weld County and no member of their governing bodies shall have any
pecuniary interest,direct or indirect,in the approved Agreement or the proceeds thereof.
7. WPCl/Mayfield assures that they will comply with the Title VI of the Civil Rights Act of 1986 and that no
person shall,on the grounds of race,creed,color,sex,or national origin,be excluded from participation in,
be denied the benefits of,or be otherwise subjected to discrimination under this approved Contract.
8. WPCUMayfield assures that sufficient,auditable,and otherwise adequate records that will provide
accurate,current, separate,and complete disclosure of the status of the funds received under the Contract
are maintained for three(3)years or the completion and resolution of an audit. Such records shall be
sufficient to allow authorized local,Federal,and State auditors,and representatives to audit and monitor
Mayfield.
9. All such records,documents,communications,and other materials shall be the property of Social Services
and shall be maintained by Mayfield,in a central location and custodian,in behalf of Social Services, for a
period of four(4)years from the date of final payment under this Contract,or for such further period as
may be necessary to resolve any matters which may be pending,or until an audit has been completed with
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Contract Number 05-06-CPS-53
the following qualifications: If an audit by or on behalf of the federal and/or state government has begun
but is not completed at the end of the four(4)year period,or if audit findings have not been resolved after
a four(4)year period,the materials shall be retained until the resolution of the audit finding.
10. WPCI/Mayfield assures that authorized local,federal,and state auditors and representatives shall,during
business hours,have access to inspect any copy records,and shall be allowed to monitor and review
through on-site visits,all contract activities, supported with funds under this Contract to ensure compliance
with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the
performance of the Agreement shall be conducted by appropriate funding sources. The results of the
monitoring and evaluation activities shall be provided to the appropriate and interested parties.
11. This Contract shall be binding upon the parties hereto,their successors,heirs,legal representatives,and
assigns. WPCI/Mayfield or Social Services may not assign any of its rights or obligations hereunder
without the prior written consent of both parties.
12. WPCl/Mayfield certifies that federal appropriated funds have not been paid or will be paid,by or on behalf
of Mayfield,to any person for influencing or attempting to influence an officer or employee of an agency,
a Member of Congress,an officer or employee of Congress,or an employee of a Member of Congress in
connection with the awarding of any Federal contract,the making of any federal grant,the making of any
federal loan,the entering into of any cooperative agreement,and the extension,continuation,renewal,
amendment,or modification of any Federal contract,loan,grant,or cooperative agreement.
13. WPCl/Mayfield assures that it will fully comply with all other applicable federal and state laws.
WPCUMayfield understands that the source of funds to be used under this Contract is Child Welfare
Regular Administration funds.
14. WPCUMayfield assures and certifies that it and its principals:
a. Are not presently debarred,suspended,proposed for debarment,declared ineligible,or voluntarily
excluded from covered transaction by a federal department of agency.
b. Have not,within a three-year period of preceding this Agreement,been convicted of,or had a
civil judgment rendered against them for commission of fraud or a criminal offense in connection
with obtaining,attempting to obtain,or performing a public(federal,state,or local)transaction or
contract under a public transaction;violation of federal or state antitrust statutes or commission of
embezzlement,theft,forgery,bribery,falsification or destruction of records,making false
statements,or receiving stolen property;
c. Are not presently indicted for or otherwise criminally or civilly charged by a government entity
(federal,state,or local)with commission of any of the offenses enumerated in paragraph 11(b)of
this certification; and
d. Have not within a three-year period preceding this Contract,had one or more public transactions
(federal,state,and local)terminated for cause or default.
15. The Appearance of Conflict of Interest applies to the relationship of a contractor with Social Services when
the contractor also maintains a relationship with a third party and the two relationships are in opposition.
In order to create the appearance of a conflict of interest,it is not necessary for the contractor to gain from
knowledge of these opposing interests. It is only necessary that the contractor know that the two
relationships are in opposition.During the term of the Contract,WPCUMayfield shall not enter any third
party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing
appearance of a conflict of interest situation,WPCl/Mayfield shall submit to Social Services,a full
disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to
promptly submit a disclosure statement required by this paragraph shall constitute grounds for Social
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Contract Number 05-06-CPS-53
Services' termination,for cause,of its contract with Mayfield.
16. WPCUMayfield shall protect the confidentiality of all applicant records and other materials that are
maintained in accordance with this Contract. Except for purposes directly connected with the
administration of Child Protection,no information about or obtained from any applicant/recipient in
possession of WPCI/Mayfield shall be disclosed in a form identifiable with the applicant/recipient or a
minor's parent or guardian unless in accordance with WPCI/Mayfield written policies governing access to,
duplication and dissemination of,all such information. WPCI/Mayfield shall advise its employees,agents,
and subcontractor,if any,that they are subject to these confidentiality requirements. WPCI/Mayfield shall
provide its employees,agents,and subcontractors, if any,with a copy or written explanation of these
confidentiality requirements before access to confidential data is permitted.
17. Proprietary information for the purposes of this contract is information relating to a party's research,
development,trade secrets,business affairs,internal operations and management procedures and those of
its customers,clients or affiliates,but does not include information(1) lawfully obtained from third parties,
(2)that which is in the public domain,or(3)that which is developed independently. Neither party
shall use or disclose directly or indirectly without prior written authorization any proprietary information
concerning the other party obtained as a result of this Contract. Any proprietary information removed from
the State's site by WPCl/Mayfield in the course of providing services under this Contract will be accorded
at least the same precautions as are employed by WPCI/Mayfield for similar information in the course of
its own business.
18. The Contractor certifies it will abide by Colorado Revised Statue(C.R.S.)26-6-104,requiring criminal
background record checks for all employees,contractors,and sub-contractors.
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Contract Number 05-06-CPS-53
EXHIBIT E
CHILD WELFARE REGULAR ADMINISTRATION FUNDS
Standards of Responsibility:
WPCl/Mayfield agrees to:
1. Provide a written report to the Social Services caseworker within 24 hours of providing services to the
client;
2. When a monitored sobriety result is positive WPCl/Mayfield agrees to leave a voice mail message to the
referring caseworker within 24 hours of providing the service.
3. Report expenditures and case disbursement at agreed upon times.
4. Submit monthly-completed billing forms to Ms. Elaine Furister,CPS/CAP,Core Services Specialist,within
twenty-five(25)calendar days of the month following service in order to receive payment. Billing forms
will not be accepted by the Department for processing after the 25h day following the service month. All
items submitted after this date will be returned to WPCI/Mayfield unpaid. Further,the Department will not
consider payments that were originally reviewed as deficient in documentation for further reimbursement.
5. In the event no service fees are incurred during the service month,an Authorization for Contractual
Services stating no services were provided for that service month shall be submitted within twenty-five
(25)calendar days following the month of service.
6. A complete and timely billing form is identified by and must include the following elements.
a. The billing must be an original billing signed by the provider and/or designee.
b. The billing must include all forms designed for Child Welfare Regular Administration funds
reimbursement and approved by Social Services including Colorado State Department of Social
Services Authorization for Contractual Services,and Weld County Monthly Request for
Reimbursement under Child Welfare Regular Administration funding.
c. Additionally,WPCl/Mayfield agrees to provide Social Services monitoring results(UA,BA,
patch,tox trap)by website no later than 72 business hours after the day of service. If the website
is not available the Contractor will provide results through fax,hand delivery,or other means. In
the event either party cannot access the results through electronic means,the Contractor will
provide the results to the caseworker. WPCl/Mayfield agrees to provide service summaries for
clients with active referrals during the billing month in order to direct issues to the caseworker and
court.
d. The Department will determine billed services not eligible for payment by identifying conflicts in
the following:
1. Details provided in client referrals,including types of service,approved hours and/or units
of service,begin and end dates of service,client name,or other client identifying
information.
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Contract Number 05-06-CPS-53
2. Details in supporting documentation provided by WPCl/Mayfield and submitted with the
original bill,including,but not limited to,original signed client verifications,receipt of
monitoring results,times of service,units or hours of service provided,and names of
clients receiving the services.
3. Details provided in the current approved contract and Notification of Financial Assistance,
including,but not limited to unit of service,cost per unit of service,and special conditions
and/or revisions to said contract.
The above items,4 d, 1,2,and 3,will supersede all requests from WPCl/Mayfield for review of
billing errors.Items submitted for billing will be processed according to the criteria established by
the above documentation.
7. Work with family to prepare to pay for services beyond established time frame.
a) Authorization for Contractual Services forms must be submitted completely filled in with an
original signature from the provider and/or designee.
b) Request for Reimbursement forms must include the client's full name;Weld County household
number,suffix number,and referral number,if applicable;units provided,service date,unit rate,
and total billed for the service date.
c) Requests for payment must be date stamped by Social Services by the 25th day of the month
following the service month.Requests for payment received after the 25th of the month following
service will not be honored.
8. Will meet with Social Services FPP Supervisor quarterly(more if needed)to review program usage and
effectiveness to discuss necessary improvements to better serve families or increase referrals;
9. Be available to meet with the Social Services staff to explain program,time lines of response to referrals
and answer questions to enhance program.
10. Be available for the Families,Youth and Children Commission review and attendance at the FYC
meetings.
•
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Contract Number 05-06-CPS-53
5310.213 (2/79)
COLORADO STATE DEPARTMENT OF SOCIAL SERVICES
AUTHORIZATION FOR CONTRACTUAL SERVICES
1. WELD COUNTY DATE:
2.
Name of Provider
3.
Address
4.
City, State, Zip
THE DESCRIBED SERVICE IS AUTHORIZED FOR THE CLIENT INDICATED:
5.
Name of Client Household# Cat. Cat. Grp.
6.
Description Sv. Code
7. APPROVAL:
Caseworker Date Co.Director or Supervisor
8.TO BE COMPLETED BY PROVIDER
DATE OF SERVICE
CHARGES$
I CERTIFY THE SERVICE AUTHORIZED WAS PROVIDED ON THE DATE INDICATED AND THE
CHARGES ARE MADE PURSUANT TO A BONA FIDE CONTRACT BETWEEN ME AND THE COUNTY
DEPARTMENT OF SOCIAL SERVICES INDICATED.
Provider Signature Date
Page 14 of 17
Contract Number 05-06-CPS-53
Prepare in Triplicate,Original and One copy to Provider,One Copy for Pending File.
Completed Provider's Forms-Original to County Finance Office-Copy to Case Record.
Page 15 of 17
Contract Number 05-06-CPS-53
COUNTY MONTHLY REQUEST FOR REIMBURSEMENT UNDER CHILD WELARE REGULAR ADMINISTRATION FUNDING
Remit to: Elaine Furister,CPS/CAP,Core Services Specialist
Name of Program Month of Service Weld County Department of Social Services
Notice to Providers: List all clients currently enrolled in your program. P.O.Box A,315 B N 11 Avenue,Greeley,CO 80632
Enter 0 if no services were provided during billing month Telephone: 970.352.1551,extension 6295
FAX: 970.346.7698
Client Name HH# Referral# Approved Approved Date of Actual Rate per Total Payment Social Services Payments Services
(If Entry Exit Date Service Hrs/Units Unit Requested Only-Comments Denied/Delayed Payable
applicable) Date
Social Service Codes: CE-Computation Error;NR-No Referral; EED-Exceeds End Date;EMH-Exceeds Maximum Hours; EMS-Exceeds Maximum Sessions;
NP-Not Payable;
PD-Payment Delayed; SPD;Submitted Past Deadline;NDC-No Face to Face Contact;NV-No Client Verification;ICMP-Initial Case Management Plan Needed;
PR-Progress Report Needed
Page 16 of 17
Contract Number 05-06-CPS-53
WELD COUNTY RE-BILL UNDER CHILD WELFARE REGULAR ADMINISTRATION FUNDS AND ADDITIONAL REQUEST FOR REIMBURSEMENT
Remit to: Elaine Furister,CPS/CAP,Core Services Specialist
Name of Program Month of Service Weld County Department of Social Services
P.O.Box A,315 B N II Avenue,Greeley,CO 80632
Telephone:970352.1551,extension 6295 FAX:970.346.7698
Client Name HH#&Client Referral# Month of Re-bill Approved Approved Actual Rate per Re-bill Certified Letter and (DSS Only)
Suffix Service amount Entry Date Exit Date Hrs/Units Unit Total Documentation Payable or
(Example: Re-billed Attached Not payable
11111-02) (include reason ifr
Social Service Codes:CE-Computation Error;NR-No Referral;EED-Exceeds End Date;EMH-Exceeds Maximum Hours;EMS-Exceeds Maximum Sessions;NP-Not Payable;
PD-Payment Delayed;SPD;Submitted Past Deadline;NDC-No Face to Face Contact;NV-No Client Verification;ICMP-Initial Case Management Plan Needed;PR-Progress Report Needed
Page 17 of 17
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