HomeMy WebLinkAbout930095.tiff RESOLUTION
RE: APPROVE PROVIDER AGREEMENT (AUTOMATED CLAIMS SUBMISSION) WITH COLORADO
DEPARTMENT OF SOCIAL SERVICES AND AUTHORIZE CHAIRMAN TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado,
pursuant to Colorado statute and the Weld County Home Rule Charter, is vested
with the authority of administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with a Provider Agreement (Automated
Claims Submission) between Colorado Department of Social Services and Weld County
Health Department, commencing on or around February 1, 1993, with the 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, that the Provider Agreement (Automated Claims Submission)
between Colorado Department of Social Services and Weld County Health Department
be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chairman be, and hereby is,
authorized to sign said agreement.
The above and foregoing Resolution was, on motion duly made and seconded,
adopted by the following vote on the 25th day of January, A.D. , 1993.
ATTEST: Pdaah
BOARD OF COUNTY COMMISSIONERS
WEELL COUNTY, COLORADO
Weld County Clerk to the Board
onstance L. Harbert, hairman
BY:
Deputy Cler to the Board _.— W. H. W bster, Pro- em
APPROVED AS FORM:
ge E Baxter
County Attorney Dale K. Hall
Barbara J. Kirkmeye
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Provider Agreement
(Automated Claims Submission)
This Agreement is made by and between the Colorado Department of Social
Services, herein called CDSS, and Weld County Health Department/04421095 04005542
PROVIDER NAME/PROVIDER NUMBER
herein called "Provider".
It is understood that this Agreement is subject to modification, revision or
termination due to changes in the contracts between CDSS and the Department of
Health and Human Services, changes in Federal or State laws, regulations
pertaining to Medicaid or changes in benefits as administered by CDSS. This
Agreement will be deemed modified, revised or terminated, to comply with any
change on the effective date of such change.
In consideration of CDSS agreeing to permit Provider to submit claims by means
of an electronic medium in lieu of written requests for payment, Provider
agrees:
1 . That claims will be submitted to CDSS in the specific format required by
CDSS, as is described in the CDSS' s Billing Manual (containing
instructions to billers) as they may be amended from time to time.
2. That the Secretary of Health and Human Services, his or her designee(s)
or agent(s) , or the CDSS or its designee(s) and the Colorado Medicaid
Fraud Control Unit (MFCU) (see 42 CFR 455.21 (a)(2)) , has the right to
audit and confirm for any purpose any information submitted by the
Provider and shall be permitted access to claim documentation records and
original source documentation, including provider signatures, medical and
financial records in the office of the Provider or any other place for
that purpose. -Any and all incorrect payments discovered, as a result of
such audit, will be adjusted according to the applicable provision of the
Social Security Act, as amended, Federal or State Regulations, or HCFA
and/or CDSS' s guidelines, or other applicable statute.
3. That the Provider accepts responsibility for any and all claims submitted
to CDSS, to research and correct any and all billing or claims
discrepancies submitted under this Agreement and that CDSS will be held
harmless for any claims, costs or damages incurred as a result of such
discrepancies.
4. That all original source documents and source records (e.g.
medical /financial records and/or billing statements) will be maintained
in such a way that all electronic medium claims can be readily associated
and identified by source documents, including provider signature or
signatures on behalf of the provider. All original source documents will
be retained for a period of six (6) years following the date of
submission to CDSS.
CDSS (4/88) 1 of 5
5. That each claim represents services or supplies actually furnished by the
Provider identified on the electronic medium claim; that each claim has
corresponding original source documents as referenced in this Agreement
and 10 CCR 2505-10 8.130 etc. ; and that no claims will be submitted to
CDSS which the Provider knows or has reason to-know conflicts with the
Social Security Act, as amended, Federal or State Regulations, or HCFA
and/or CDSS' s guidelines .
6. That the submission of an electronic medium claim to CDSS is a claim for
payment from public funds of the United States and the State of Colorado,
that anyone who misrepresents or falsifies any record or other
information essential to that claim or that is required pursuant to this
Agreement may, upon conviction, be subject to fine and imprisonment under
Federal or State laws, and that the required provider signatures ,
appropriate signatures on behalf of providers, dated provider signatures ,
certifications, or recertifications exist and are available in accordance
with prescribed procedures.
7. CDSS has the right not to accept claims via the electronic media covered
by this Agreement. This CDSS right does not affect existing Provider
rights to submit paper claims.
8. If a duly licensed group medical practice, the Provider must give CDSS
advance written notice of any changes in the status, including names and
other appropriate identifiers, or physicians within the group.
9. To give CDSS advance written notice of any contractual arrangement with
an individual , partnership or corporation engaged to perform billing
services or claims submissions on behalf of Provider.
10. To make revisions immediately if mandated by Federal , State and/or CDSS' s
specifications. ,
11 . That CDSS or its fiscal agent shall have no obligation for the
reconstruction or the replacement of lost or damaged tapes, or for the
reconstruction of claims data lost during electronic transmission for
whatever reason. It is required that the Provider establish and maintain
backup procedures and records/claims.
12. Provider understands that this Agreement does not eliminate other
obligations under the individual Participating Agreements which Provider
has with CDSS.
13. To establish and maintain procedures and controls so that information
concerning Medicaid Recipients, or any information obtained from the
Department of Health and Human Services or its agents, shall not be used
by the agents, officers or employees of Provider except as provided in
the Social Security Act, the Freedom of Information Act, the Privacy Act,
as amended, and the Federal Regulations prescribed thereunder.
CDSS (4/88) 2 of 5 0730935
14. Not to disclose any information concerning a Medicaid recipient to any
person or organization other than the Secretary of Health and Human
Services, his or her designee(s) or agent(s) , CDSS or its designee(s) ,
and the MFCU without the express written permission of the Medicaid
recipient or his or her lawful representative.
15. I further agree that all claims represent services medically indicated
and necessary for the health of the patient and were personally rendered
by me or were rendered incident to my professional service by my employee
under immediate personal supervision, except as otherwise expressly
permitted by Medicaid regulations. Some of the mandatory prerequisites
for properly claiming payment for physician' s services delivered by
anyone other than the physician provider are set forth below.
For services to be considered an ' incident' to a physician' s professional
service, I ) they must be rendered under the physician' s immediate
personal supervision by his/her employee, 2) they must be an integral ,
although incidental part of a covered physician's service, 3) they must
be of kinds commonly furnished by physicians, 4) the services of
non—physicians must be billed in accordance with CDSS guidelines and
regulations , 5) the physician' s employees must be acting consistently
with the Colorado Medical Practice Act and rules and regulations issued
thereunder, and 6) the physician provider must be physically on the
premises when the service is provided.
16. I understand that this Provider Agreement is to be renewed annually and
that I am responsible for initiating the renewal with the fiscal agent.
All claims reimbursed under an expired Agreement are subject to recovery.
17. The parties recognize that, but for this Agreement or other provision of
law, the Provider would have the right to protection from government
inspection of the Provider's bus.iness. operations. under various
constitutional and statutory provisions, including certain portions of 18
U.S.C. 2701 , etc. , known as the Electronic Communications Privacy Act.
The Provider expressly waives such rights, and consents to the access
contemplated by 10 CCR 2505-10 8.130, etc. By voluntarily entering this
Agreement, the Provider voluntarily and knowingly consents to the
government' s having access to electronically stored and electronically
transferred information directly and indirectly used, relied upon, or
referred to in the preparation of electronically transmitted Medicaid
claims. The Provider understands that the Provider, the Provider' s
employees, the Provider' s agents, and each remote computing service and
its employees with information pertaining to the preparation and
submissionn of the Provider' s claims , are subject to the requirements and
duties of 10 CCR 2505-10 8. 130, etc. , which addresses the requirements of
disclosure upon providers in the Colorado Medicaid Program. It is
understood that the requirements of disclosure include, but are not
necessarily limited to, such items as contracts, letters , memoranda,
diagrams, "electronic mail ", numerical data, instructions, operating
manuals, inquiries, corrections , directories , lists and other writings
CDSS (4/88)
3 of 5
and other data compilations of whatever description used, relied upon or
referred to in the origination, preparation, generation, transmission ,
reception, or interpretation of Medicaid claim forms by the Provider, the
Provider's agents, the Provider's employees, or the Provider' s remote
computing service. Such information will be provided upon request of the
requesting agency and in the medium specified by the requesting agency.
The parties acknowledge that failure to comply with the requests for
information of the requesting agency can result in exclusion from
Medicare and Medicaid participation pursuant to Federal and State
statutes and regulations, including 42 U.S.C. 1320(a) , and other
provisions of the Medicare and Medicaid Patient and Program Protection
Act of 1987, Public Law 100-93.
18. The Provider understands that the submission of a claim is the Provider' s
respresentation that the information transmitted is true and that the
claim is submitted in conformity with this Agreement. The Provider
understands that knowingly obtaining funds by means of a false
representation made through the use of a computer or a computer system
can represent a violation of Section 18-5.5-102 C.R.S. (1986) , 42 U.S.C.
1396(h), 18 U.S.C. 1001 and other State and Federal statutes.
19. I will accept as payment in full , payment made under the Colorado Medical
Assistance Program and certify that no supplemental charges have been or
will be billed to the patient, except for any items or services which are
not reimbursed under the Colorado Medical Assistance Program. I agree
not to bill the patient for covered items and services which would have
been reimbursable under the program, had I complied with the rules and
regulations of the Colorado Medical Assistance Program.
20. Items and services provided by me are available without discrimination as
to race, color, religion, age (except as provided by law) , sex, marital
status, political affi.liat.ion, handicap, •or national. origin. I hereby
certify compliance with Section 504 of the Rehabilitation Act of 1973
which provides that "no otherwise qualified handicapped
individual . . .shall , solely by reason of handicap, be excused from
participation in, be denied the benefits of, or be subjected to
discrimination under any program activity receiving Federal financial
assistance.
CDSS (4/88) 4 of 5
This Agreement may be terminated at any time by the Provider, CDSS or Federal
or State Agencies upon written notice. Written notice will be deemd received
on the date is is handed to the other party or the date is placed in the mail
if the mail is used.
PROVIDER: COLORADO DEPARTMENT OF SOCIAL SERVICES:
Weld County Health Department By
NAME
Date
CORPORATION NAME
04421094 04005542
PROVIDER NUMBERS
BOARD OF COUNTY COMMISSIONERS
SIGNATURE($ CJF' AUTHORIZED PERSON(S) WELD COUNTY, COLORADO
Date f
FEDERAL TAX ID!/ 84-6000-813 BY: --r _
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ATTES
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WELD COUNTY CLERK TO THE
�BOARD
BY: iL+✓4-CP� .1/ �"" `.`-
Deputy clerk to the Board
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ATTESiI; G C. ..
C0N ::2RU1 S'',GP:ATURES ONLY
CDSS (4/88)
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