HomeMy WebLinkAbout930096.tiff RESOLUTION
RE: APPROVE PROVIDER AGREEMENT (AUTOMATED CLAIMS SUBMISSION) WITH ROCKY
MOUNTAIN HOSPITAL AND MEDICAL SERVICES, DBA BLUE CROSS AND BLUE SHIELD OF
COLORADO, 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 Rocky Mountain Hospital and Medical Services, dba Blue
Cross and Blue Shield of Colorado, and Weld County Health Department, commencing
on or about 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 Rocky Mountain Hospital and Medical Services, dba Blue Cross and Blue
Shield of Colorado, 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.
/J 4 BOARD OF COUNTY COMMISSIONERS
ATTEST:
�� �' / 1 WELD COUNTY, COLORADO
Weld County Clerk to the Board
,/ /n Constance L. Harbert, Chairman ate
BY: Deputy C erk to the rd W. H. W bster, Pro- em
APPROVED AS T FORM: c / ,
G orge �Baxter
County Attorney Da1�,Hall
dbara J j /\ <_/YCit /tom
$arbara J. Kirkmeye U
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Blue Cross c r �1Z7
Blue Shield
of Colorado -
700 Broadway
Denver,Colorado 80273
PROVIDER AGREEMENT
(AUTOMATED CLAIMS SUBMISSION)
This Agreement is made by and between Rocky Mountain Hospital and Medical Services, dba Blue Cross
and Blue Shield of Colorado, herein called "Corporation", and Weld County Health Department
PROVIDER NAME
herein called "Provider".
It is understood thatthis Agreement is subject to modification,revision or termination due to changes in the
contracts between the Corporation and the Department of Health and Human Services, the Colorado
Department of Social Services, changes in Federal or State laws, regulations pertaining to Medicare or
changes in health coverage plans as underwritten or administered by Corporation.This Agreement will be
deemed modified, revised or terminated,to comply with any change on the effective date of such change.
In consideration of the Corporation 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 the Corporation in the specific format required by the Corporation,as
is described in the Corporation's User Specifications 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 Corpora-
tion 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 patient 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 provisions of the Social Security Act, as amended, Federal or
State Regulations, or HCFA and/or Corporation's guidelines.
(3) That the Provider accepts responsibility for any and all claims submitted to the Corporation, to
research and correct any and all billing or claims discrepancies submitted under this Agreement and
that the Corporation 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 patient signature or signatures on behalf
of the patient. All original source documents will be retained for a period of seventy-two months
following the date of submission to the Corporation.
(5) That all claims represent services or supplies actually furnished by the Provider identified on the
electronic medium claim; that all claims have corresponding original source documents as refer-
enced in this Agreement;and that no claims will be submitted to the Corporation which the Provider
knows or has reason to know conflict with the Social Security Act, as amended, Federal or State
Regulations, or HCFA and/or Corporation's guidelines.
(6) That the submission of an electronic medium claim to the Corporation is a claim for payment, 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 patient signatures, appropriate signatures on
behalf of patients, certifications, or recertifications are available in accordance with prescribed
procedures.
(7) The Corporation has the right not to accept claims via the electronic media covered by this Agree-
ment. This Corporation right does not affect existing Provider rights to submit paper claims.
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(8) If a duly licensed group medical practice, to give the Corporatior, ,dvance written notice of any
changes in the status, including names and other appropriate identifiers, or physicians within the
group.
(9) To give Corporation 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 Corporation's specifications.
(11) That Corporation 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 recommended that Provider establish and maintain backup procedures and
records/claims.
(12) Provider understands that this Agreement in no way modifies the individual Participating Agree-
ments which Provider has with the Corporation.
(13) To establish and maintain procedures and controls so that information concerning Medicare benefi-
ciaries, 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.
(14) Not to disclose any information concerning a Medicare beneficiary to any person or organization
other than the Secretary of Health and Human Services, his or her designee(s)or agent(s),and the
Corporation without the express written permission of the Medicare beneficiary 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 Medicare or CHAMPUS regulations.
For services to be considered an 'incident' to a physician's professional service, 1) 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 in physician's offices, and 4)the services of non-physicians must be included
on the physician's bills.
This Agreement may beterminated at any time by the Provider,the Corporation or Federal or State Agencies
upon written notice.Written notice will be deemed received on the date it is handed to the other party or the
date it is placed in the mail if the mail is used.
PROVIDER: CORPORATION:
Weld County Health Department Blue Cross and Blue Shield of Colorado
INDIVIDUAL NAME
By
CORPORATION NAME
1517 16th Ave. Court, Greeley, CO 80631 Date:
ADDRESS
(303) 353-0586
TELEPHONE NUMBER
1095 04005542
P /ICIER NUMBERISI
SIGNATUREISI OF AUTHORIZED PERSONS) 01/27/93
Constance L. Harbert, Chairman
Weld County Board of Commissioners
Date 01/25/93
9307;3
FORM NO.94229(REV-10-881
f mEmORAnDUm
7o Constance L. Harbert, Chairman
Board of County Commissionersrs
Date January 18, 1993
Ji
COLORADO Jeannie K. Tacker, Business Manager, Weld County Health Dept. i 0Nr
From
Subject: Provider Agreements with Blue Cross/Blue Shield
Enclosed for Board approval and signature are two provider agreements between the
Weld County Health Department and Blue Cross/Blue Shield of Colorado. The
agreement covers the terms and responsibilities of each party for automated
submission of Medicaid reimbursement claims. The Health Department as part of
the new client database, will begin automated Medicaid billing on or around
February 1, 1993.
I would recommend your approval of these agreements.
If you have any questions, please feel free to contact me.
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