HomeMy WebLinkAbout952284.tiff RESOLUTION
RE: APPROVE ANCILLARY SERVICES AGREEMENT BETWEEN AMBULANCE SERVICE
AND COLORADO ACCESS 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 an Ancillary Services Agreement between
the County of Weld, State of Colorado, by and through the Board of County Commissioners of
Weld County, on behalf of the Ambulance Service, and Colorado Access,with 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 Ancillary Services Agreement between the County of Weld, State of
Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Ambulance Service, and Colorado Access 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 6th day of November, A.D., 1995.
BOARD OF COUNTY COMMISSIONERS
W�UNTY, C•LORADO
i�""""��-�`^.. ='a ► / ' t Dale K. Hall, Chairman
, WA Court Clerk to the Board
i
' ' FXCIISM IIATF nF SIANINr (AYF1
'' , 4 cD _i Barbara J. Kirkmeyer, ro-Tem
` Deputy Cler �t the Board ��� 'r-- '
'Geo e4. Baxter
APP D AS TOrt. I 2-5 -74:-r.e--64. .:Zeate-
Constannce L. Harbert
ntyAt ey (/ /0. % //,a ,, %r i
W. H. Webster
952284
AM0009
_ .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ..
6 WELD COUNTY ATTORNEY'S OFFICE
PHONE: (970) 356-4000, EXT. 4391
FAX: (970) 352-0242
915 TENTH STREET
W� C• P.O 1948
Q GREELEY, COLORADO DO 80632
COLORADO
March 19, 1996
LETTER TO THE FILE
RE: Contract for Ambulance Services with Colorado Access
The Board previously considered and approved by Resolution in November, 1995, a contract
known as the Ancillary Services Agreement between the ambulance service and Colorado
Access. The Agreement that was considered and approved had been submitted by FAX, with the
hard copy to follow. The terms and provisions that were approved were not accurately reflected
in the hard copy that was submitted for signature. For example, the amounts that were to be paid
were incorrectly stated in the final document. There were other discrepancies in the final
document, which resulted in several proposed "final documents" being sent back and forth
between Weld County and Colorado Access. Finally, there was a meeting between
representatives of the ambulance service and Colorado Access, and an agreement was reached
concerning the format of the final document. The attached agreement accurately reflects the
provisions and dollar amounts that the Board previously approved in the November Resolution,
although the title and format in the agreement have been changed.
Cyndy iauqu U
ColoradoA.cc ess
r 1 A•a4F ran/rv,n—Nupfe Jeu Mw
April 19, 1996
Gary M. McCabe, Director
Weld County Ambulance Service
1121 M Street
Greeley, CO 80631
Dear Gary:
Enclosed is your copy of the executed Ambulance Service Agreement between Colorado Access and
Weld County Board of County Commissioners, on behalf of the Weld County Ambulance Service.
We will be pleased to answer any questions or address any concerns you may have, and invite you to call
Shelli Dore in our Provider Relations Department at either 800/511-5010 or 303/333-8900 at your
convenience.
We look forward to a successful and mutually beneficial long-term relationship with you.
Sincer
David Hlavac
Dir. of Business&Network Development
Enclosure
600 S. CHERRY STREET,SUITE 325,DENVER,CO 80222.303/333-8900. 1-800/511-5010•FAX 303/333-7145
COLORADO ACCESS
AMBULANCE SERVICES AGREEMENT
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This Agreement is entered into this y day of , 199 , by and between
COLORADO ACCESS, a Colorado non-profit corporation (`COLORADO ACCESS"), and
Weld County Board of County Commissioners, on behalf of the Weld County Ambulance
Service ("WCAS"), located at 1121 M Street, Greeley, Colorado 80631.
WITNESSETH:
WHEREAS, COLORADO ACCESS is engaged in the business of providing or
arranging for pre-paid health care services to Members in Colorado and has a Colorado Medical
Assistance Program Contract with the Department of Health Care Policy and Financing (the
"Department"); and
WHEREAS, COLORADO ACCESS wishes to engage the services of WCAS to provide
Covered Services as defined in Appendix A to its commercial, Medicare and Medicaid Members;
and
WHEREAS, WCAS has the necessary credentials and is willing and able to provide
Advanced Life Support ("ALS"), Basic Life Support("BLS"), and Non-Emergent transportation
services to COLORADO ACCESS Members; and
WHEREAS, WCAS is willing to provide the services desired by COLORADO ACCESS
under the terms and conditions hereinafter set forth;
NOW THEREFORE, in consideration of the above premises and the mutual covenants
of the parties, it is agreed as follows:
1. DEFINITIONS. The terms used in this Agreement shall have the meanings
defined in Appendix A to this Agreement.
2. TERM AND RENEWAL. This Agreement shall be effective for one (1) year
from the date first above written and thereafter shall continue in effect from year to year unless
terminated by either party pursuant to the terms of this Agreement.
3. WCAS SERVICES.
A. Provider Credentialing. All health care professionals employed, retained
or used by WCAS must be licensed or otherwise authorized by law to provide health care related
services in the State of Colorado. WCAS shall at all times comply with the requirements of
Weld County Ordinance 77-C, or its successor, a copy of which is attached hereto and
incorporated herein, which requires that documentation of the certification of all health care
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professionals employed, retained or used by WCAS be kept current with the County. The parties
acknowledge that a current permit to operate an ambulance service in Weld County is reliable
evidence that WCAS has complied with the requirements of Weld County Ordinance 77-C, or its
successor.
B. Services. WCAS agrees to provide appropriate emergency services and
other Covered Services to Members, as hereinafter set forth in this Agreement. Non-emergent
services shall be provided upon proper referral authorized by COLORADO ACCESS.
(a). Ouality of Services. WCAS shall provide such services in the same
manner, in accordance with the same standards, and within the same time availability, as offered
its other patients. WCAS shall comply with all non-medical policies and procedures established
by COLORADO ACCESS, including, but not limited to, those applicable to ALS, BLS, and
non-emergent transportation services, quality/utilization management and cost containment
programs, in a manner which is consistent with sound medical practice.
C. Referrals and Approval by Colorado Access.
(a). Non-Emergent Services. Any and all non-emergent transportation services
for which COLORADO ACCESS is responsible for payment must be documented and referred
to COLORADO ACCESS via phone, fax or mail for approval by COLORADO ACCESS prior
to provision of such service.
(b). Emergency Services. Emergency services provided by WCAS shall not
require approval from COLORADO ACCESS prior to rendering services. WCAS shall notify
COLORADO ACCESS within 24 hours, or as soon thereafter as is practical, of all emergency
services provided to COLORADO ACCESS Members.
D. Service Standards and Performance Guarantees.
(a). Service Standards. WCAS shall adhere to the following specified service
standards for non-emergent services:
(1). Telephone Calls. All telephone calls for ALS and BLS services,
as well as for non-emergent services will be received from the 911 telephone system, which is
available 24 hours per day.
(2). Prior Authorization for Non-Emergent Services. Non-emergent
transport services which are ordered by the COLORADO ACCESS Physician or Case Manager
shall be confirmed prior to the delivery of such services by WCAS.
(3). Good Faith Effort to Provide Timely Non-Emergent Services.
Every effort shall be made to provide non-emergent services at the scheduled time; however, in
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no event shall the provision of such non-emergent services be delayed beyond the scheduled time
by more than two (2) hours, without promptly notifying the COLORADO ACCESS Physician or
Case Manager. The COLORADO ACCESS Physician or Case Manager will be notified, in any
case, if the delivery of any non-emergent service will be delayed beyond the scheduled time.
WCAS shall be able to schedule or provide all non-emergent transports within 24 hours of
referral except as otherwise arranged with the COLORADO ACCESS Physician or Case
Manager. COLORADO ACCESS acknowledges that non-emergent transports cannot be
accommodated when all available ambulances are in use or on reserve for emergency services.
(4). Compliance with Written Protocols and Standard Operation
Procedures. Emergency services shall be provided to COLORADO ACCESS Members in
compliance with the written protocols and standard operating procedures of WCAS.
E. Complaints. Complaints shall be responded to by WCAS in a timely
manner. Written response to a complaint or service inquiry, communicated either orally or in
writing by COLORADO ACCESS, or a COLORADO ACCESS patient, physician or staff
member, shall be made within 10 business days of receipt of such complaint. Records of all
complaints received by WCAS from COLORADO ACCESS, or a COLORADO ACCESS
Member, physician or staff member, will be kept on file until such time that COLORADO
ACCESS no longer requires that such records be kept, or six (6) years, whichever sooner occurs.
F. Grievances. WCAS agrees to participate in and be bound by the
grievance procedures adopted by COLORADO ACCESS pursuant to state or federal
requirements, effective on the date of execution of this Agreement, or as hereafter amended, after
notification by COLORADO ACCESS of such amendment, pursuant to the provisions for
modification set forth hereinafter.
4. COMPENSATION.
A. Billing for Services. WCAS shall bill COLORADO ACCESS for Covered
Services rendered by WCAS to Members. WCAS shall bill Members or the appropriate fiscal
agent directly for any non-covered services rendered to Members at the Claims Address set forth
in the Provider Manual as defined in Appendix A, and provided to WCAS.
(a). Rates and Fees for Services. WCAS shall bill COLORADO ACCESS for such
Covered Services at the rates and fees described in Appendix B, such amounts to be accepted by
WCAS as payment in full for the rendition of said services. The billing statement shall include
detailed and descriptive medical service and patient data and identifying information.
(b). Payment for Services. COLORADO ACCESS agrees to make payment in full to
WCAS within forty-five (45) days after receipt of a"clean" billing statement, as defined in
Appendix A, or to provide WCAS with a written request for additional information within forty-
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five (45) days after receipt of an inaccurate or insufficient billing statement. Based on the
response to said request, COLORADO ACCESS may either deny the claim or make payment in
full to WCAS within forty-five (45) days after receipt of the subsequently issued"corrected"
billing statement.
(c). Limitation of Billing. WCAS shall present COLORADO ACCESS with the
billing statement within six (6) months from the date of rendition of Covered Services to
Members. Failure to submit the "clean" billing statement within the specified six (6) months
from the date of rendition of Covered Services will result in automatic denial of the claim.
B. Members Not Responsible for Payments for Covered Services. WCAS agrees
that in no event, including but not limited to non-payment by COLORADO ACCESS,
insolvency of COLORADO ACCESS or breach of this Agreement, shall WCAS bill, charge,
collect a deposit from, seek compensation, remuneration or reimbursement from, or have any
recourse against a Member or persons (other than COLORADO ACCESS) acting on Member's
behalf for services provided pursuant to this Agreement. This provision does not prohibit WCAS
from collecting supplemental charges or co-payments or fees for uncovered services delivered on
a"fee-for-service" basis to Members.
(a). Survival of this Provision. WCAS agrees that this provision 4B. shall survive the
termination of this Agreement, for authorized services rendered prior to the termination of this
Agreement, regardless of the cause giving rise to termination and shall be construed to be for the
benefit of Members. This provision 4B. is not intended to apply to services provided after this
Agreement has been terminated.
(c). This Provision Supersedes any other Contrary Agreement. WCAS agrees that
this provision 4B. supersedes any oral or written contrary agreement now existing or hereafter
entered into between WCAS and Member or persons acting on Member's behalf insofar as such
contrary agreement relates to liability for payment of services provided under the terms and
conditions of this Agreement.
(d). Modification of the Provision. Any modification, addition, or deletion to this
provision 4B. shall become effective on a date no earlier than thirty (30) days after Colorado's
Division of Insurance has received written notification of proposed changes.
5. RECORDS.
(a). Medical Records. WCAS shall initiate and maintain legible, comprehensive and
chronological medical records documenting each episode of service to Members and detailing, as
appropriate, history, physical finding, assessments, and treatment plans. If a Member has
executed an Advance Directive, and WCAS has been made aware of the Advance Directive, this
shall be included as part of the Member's medical record. WCAS agrees to maintain Members'
medical records in a form which is in accordance with the general standards applicable to such
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books or record keeping.
(b). Services Standards Compliance Records. WCAS agrees to provide access to any
pertinent information to COLORADO ACCESS concerning WCAS's compliance with the above
set forth services standards. Both WCAS and COLORADO ACCESS agree to develop report
formats and data fields that will be mutually agreed upon.
(c). Access to Pertinent Records. WCAS agrees to provide access to any pertinent
information to COLORADO ACCESS upon request, so that COLORADO ACCESS may
regularly survey Members to determine Members' satisfaction with the services provided by
WCAS.
(d). Confidentiality. COLORADO ACCESS and WCAS agree that medical records
of Members shall be treated as confidential so as to comply with all federal and state laws and
regulations regarding the confidentiality of medical records.
6. REPORTS. The following reports, subject to modification by COLORADO
ACCESS at a later time, shall be provided to COLORADO ACCESS no later than the 10th of
each month for services rendered during the previous month:
(a). Classification, Distance and Cost Report: By patient name, Medicaid ID
number or SSN, assessment or chief complaint, type of services authorized, date service request
received, date services initiated, date services provided, type of transport, transport code/class,
total number of miles transported, total costs of services; average distance and total cost of
services for all patients.
(b). No-Service Reports. Trip Reports to document by patient name, Medicaid ID
number or SSN, the reasons for services not delivered.
7. QUALITY AND UTILIZATION MANAGEMENT.
(a). Members' records. Subject to applicable federal and state laws regarding
privacy and confidentiality requirements, WCAS shall make Members' records available to
COLORADO ACCESS and its Quality Management ("QM") and Utilization Management
("UM") personnel. WCAS's obligations shall include, but not be limited to, (I) providing
COLORADO ACCESS copies of all records pertaining to treatment of Members; (ii) allowing
QM and UM personnel access to Members' records on WCAS premises during its regular
business hours; and (iii)transmitting Members' records information by telephone to
COLORADO ACCESS, for purposes of QM or UM.
(b). Cooperation by WCAS. WCAS agrees to cooperate with COLORADO
ACCESS in any Quality Management and Utilization Management that COLORADO ACCESS
may be conducting, or other program of review being conducted by COLORADO ACCESS to
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promote high standards of medical care and to control costs. WCAS's cooperation shall include,
but not be limited to, providing access to such records as are necessary for the evaluation of the
quality, appropriateness and timeliness of service performed under this Agreement; providing
access to Members' medical records, as appropriate; providing access to the premises so that
COLORADO ACCESS may inspect, monitor or otherwise evaluate the performance of WCAS's
activities pursuant to this Agreement; and the like. All inspections, audits, or reviews of WCAS
records or activities shall be conducted during regular business hours, and shall not unduly
interfere with the performance of WCAS's activities.
8. GOVERNMENTAL REQUIREMENTS.
(a). Records to be maintained for 6 years. WCAS shall maintain complete and
accurate fiscal records, as well as medical records, applying solely to Members for whom WCAS
has claimed and received payment. WCAS shall maintain such records as are necessary for the
evaluation of the quality, appropriateness and timeliness of service performed under this
Agreement. Said records will be made available for fiscal audit, medical audit, medical review,
QM, UM, and other periodic monitoring upon request of authorized representatives of
COLORADO ACCESS or authorized federal and state regulating agencies. Medical records or
copies thereof shall be provided upon request of COLORADO ACCESS or authorized federal
and state regulating agencies. WCAS further agrees to comply with requirements issued as a
result of any such inspection or audit. In addition, WCAS shall maintain, for the Department's
review, all written procedures, materials, data, systems and forms required by this Agreement.
Said records shall be retained for a period of at least six (6) years after the starting date of the
applicable retention period and further pending the resolution of any ongoing audit.
(b). Access by Government to Records. Upon the request of authorized federal and
state regulating agencies, WCAS shall, during normal business hours, provide access to WCAS's
premises to inspect, audit, monitor or otherwise evaluate the performance of WCAS's activities
pursuant to this Agreement. WCAS shall, upon request, make available staff to assist in the audit
or inspection effort and provide adequate space on the premises to reasonably accommodate the
state or federal personnel conducting the audit or inspection. All inspections or audits shall be
conducted in a manner as will not unduly interfere with the performance of WCAS's activities.
9. MARKETING. WCAS agrees that COLORADO ACCESS may include WCAS
address and telephone information in any and all lists of providers compiled by COLORADO
ACCESS for its Members. COLORADO ACCESS may include WCAS in any and all
marketing and advertising materials which have been pre-approved by WCAS.
(a). No Material Incentives or Inducements. WCAS and/or its subcontractors are
prohibited from providing material incentives unrelated to the provision of services pursuant to
this Agreement as an inducement to enroll or disenroll Members.
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10. NOTIFICATION TO RELOCATE. WCAS currently maintains its main office
at the facility identified in the introductory paragraph of this Agreement, and also as set forth in
Appendix C of this Agreement. WCAS provides emergency, as well as non-emergent services at
all locations throughout Weld County where WCAS services are required. WCAS agrees to
provide COLORADO ACCESS with written notice thirty (30) days in advance of a change in
location of its main office.
11. INSURANCE. WCAS shall obtain and maintain such policies of liability and
malpractice insurance as are necessary to adequately cover WCAS and its agents and/or
employees against any claim for damages, personal injuries or death occasioned directly or
indirectly in connection with the performance of any act or omission by WCAS, its agents and/or
employees. The levels of such insurance shall be, at a minimum, in compliance with the
requirements of the Colorado Statutes. Since Weld County Ordinance 77-C, or its successor,
attached hereto and incorporated herein, requires all ambulance services licensed in Weld County
to maintain such insurance, Weld County may present its Weld County ambulance permit as
proof of compliance with the insurance coverage requirements of this Agreement.
12. DISPUTE RESOLUTION. In the event of any dispute, claim, question, or
disagreement arising from or relating to this agreement, the parties shall use their best efforts to
settle the dispute, claim question or disagreement. To do so, they shall consult and negotiate
with each other in good faith and, recognizing their mutual interests, attempt to reach a just and
equitable solution satisfactory to both parties. If they do not reach such solution within a period
of thirty days, then, upon notice by either party to the other, disputes, claims, questions or
differences shall be finally settled by arbitration in Denver, Colorado, in accordance with the
then-applicable provisions of the Commercial Arbitration Rules of the American Arbitration
Association and pursuant to the Colorado Uniform Arbitration Act, as amended from time to
time, and judgment on such arbitration award may be entered in any court having jurisdiction.
Each party shall bear its own expenses in connection with any arbitration, and the fees and
expenses of the arbitrators shall be divided equally between the parties, provided, however, that
if the arbitrators determine that the position of either party was without substantial merit or was
taken in bad faith,they may require that party to bear all or any portion of the expenses of the
other party and more than one-half of the fees and expenses of the arbitrators.
A. Remedies for Failure to Meet Service Standards. WCAS agrees to perform the
above stated service standards. If at any time, COLORADO ACCESS determines that WCAS is
not performing adequately pursuant to the above stated service standards, COLORADO
ACCESS shall so notify WCAS pursuant to the notice provisions in this Agreement. WCAS
shall have thirty (30) days in which to correct the deficiency. If WCAS does not take steps to
correct any deficiency within said thirty (30) days after notice has been given by COLORADO
ACCESS, COLORADO ACCESS, at its option, may terminate this contract, pursuant to the
terms of this Agreement.
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B. Required Disclosures. WCAS shall notify COLORADO ACCESS in writing
within five (5) calendar days following the occurrence of any of the following events:
(a). WCAS's license, certification or other credentials necessary to provide Covered
Services in the State of Colorado is suspended, revoked, terminated or subject to terms of
probation or other restriction;
(b). WCAS learns or reasonably should know that WCAS has become a defendant in
any legal action, or is required to pay damages in any action by way of judgment or settlement,
having to do with negligence or misconduct in providing services.
(c). WCAS becomes the subject of any disciplinary action before the licensing board
by which WCAS is licensed or a similar agency whose license or certification is required to
operate.
(d). WCAS lacks the capacity to continue business;
(e). WCAS fails to maintain insurance coverage, or to replace coverage which is
canceled or terminates, as prescribed in paragraph 11 hereof.
C. Termination.
(a). This Agreement may be terminated by either party upon providing written notice
to the other party of its intent to terminate at least ninety (90) days in advance of such
termination.
(b). In the event either party seeks termination of the Agreement, that party shall
provide ninety (90) days' advance written notice to the Department of Health Care Policy and
Financing before terminating the Agreement.
(c). Nonpayment for goods or services rendered by WCAS to COLORADO ACCESS
shall not be a valid reason for non-compliance with the 90 day advance notice of termination.
(d). Upon receipt by COLORADO ACCESS of a 90 day termination notice,
COLORADO ACCESS may, if requested by WCAS, terminate the Agreement in less than
ninety (90) days if COLORADO ACCESS is not financially impaired or insolvent.
(e). Upon such termination, the rights of each party hereunder shall terminate,
provided however, that WCAS completes treatment of Members receiving treatment at
termination and COLORADO ACCESS makes the required payment to WCAS for all services
performed in connection with such treatment.
D. Immediate Termination. COLORADO ACCESS may terminate this Agreement
immediately, upon written notice to WCAS, if:
(a). WCAS violates any provision of this Agreement;
(b). WCAS's license, certification, or other credentials necessary to provide Covered
Services in the State of Colorado is revoked, suspended or restricted;
(c). WCAS violates any of COLORADO ACCESS's Rules and Regulations as set
forth in COLORADO ACCESS's Provider Manual as defined in Appendix A;
(d). WCAS acts in such a way that undermines or may undermine the confidence of
Members, potential Members or the public in COLORADO ACCESS or in the quality of care or
service which Members receive;
(e). Either party commits any act of bankruptcy, commences a voluntary action for
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relief as a debtor under the United States bankruptcy laws or if any bankruptcy receivership,
insolvency, reorganization, dissolution, liquidation or similar proceedings shall be instituted by
or against said party and said party consents to or files such proceeding, or if either party
generally fails to pay their debt as it becomes due;
(f). Services WCAS is providing or failing to provide,jeopardizes the health, safety
or welfare of Members.
E. Notices. Any notice required to be given pursuant to the terms and provisions
hereof shall be sent by certified mail, return receipt requested, postage prepaid, to the parties
hereto as follows:
COLORADO ACCESS: Colorado Access
Attn: Executive Director
600 South Cherry Street, Suite 800
Denver, Colorado 80222
WCAS: Weld County Ambulance Service
Attn: Gary McCabe
1121 M Street
Greeley, Colorado 80631
F. Orderly Transfer. WCAS agrees, in the event of termination of this Agreement,
to cooperate with COLORADO ACCESS in the orderly transfer of Members being treated or
evaluated.
13. GENERAL PROVISIONS.
A. Compliance With Applicable Laws. WCAS agrees to recognize and abide by
all local, state and federal laws, regulations and guidelines applicable to COLORADO ACCESS.
B. Certifications.
(A). WCAS certifies that (1) no federal appropriated funds have been paid or will be
paid by or on behalf of COLORADO ACCESS to any person for influencing or attempting to
influence an officer or employee of any 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
contract, and the extension, continuation, renewal, amendment, or modification of any contract,
grant loan or cooperative agreement that utilizes federal funds and (2) if any funds other than
federal appropriated funds have been paid or will be paid to any person for influencing or
attempting to influence an officer or employee of any agency, a member of Congress, an officer
or employee of Congress in connection with this federal contract, grant, loan, or cooperative
agreement, the contractor shall complete and submit Standard Form-LLL, "Disclosure Form to
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Report Lobbying", in accordance with its instructions.
(B). WCAS further certifies, by submission of this Agreement, that(1) neither it nor
its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in this transaction by any federal department or agency
and (2) where WCAS is unable to certify to any of the statements in this certification, WCAS
shall attach an explanation to this Agreement.
C. Assignment. Neither this Agreement nor any rights or obligations hereunder
shall be assignable by WCAS without the prior written consent of COLORADO ACCESS, nor
shall the duties imposed herein be subcontracted or delegated without the prior written approval
of COLORADO ACCESS. COLORADO ACCESS or its assignee hereunder may, however, in
any manner transfer or assign this Agreement to a parent corporation, or a subsidiary or affiliated
corporation under its control.
D. Statement of Ownership. WCAS shall, prior to the execution of this Agreement,
provide COLORADO ACCESS with a statement of ownership in WCAS's company, including
full disclosure of all individuals with a financial interest in WCAS's business.
E. Entire Agreement. This Agreement constitutes the entire Agreement between
the parties with respect to the subject matter hereof, and no modification or revision thereof shall
have any force and effect unless the same is in writing and executed by the parties hereto. The
failure of any party to insist on the strict performance of any condition, promise, agreement, or
undertaking set forth herein shall not be construed as a waiver or relinquishment of the right to
insist upon strict performance of the same condition, promise, agreement or undertaking at a
future time.
F. Severability. If any provision of this Agreement or portion thereof is declared
invalid or unenforceable, the remaining provisions shall nevertheless remain in full force and
effect.
G. Controlling Law. This Agreement shall be construed and enforced in accordance
with the laws of the State of Colorado.
H. Parties Relationship. The relationship of WCAS to COLORADO ACCESS is
that of an independent contractor. No work, act, commission or omission of any party, its agents,
servants or employees, pursuant to the terms and conditions of this Agreement, shall be
construed to make or render any party, its agents, servants or employees, an agent, servant,
representative or employee of, or joint venture with, the other party. In addition, due to the
nature of this relationship, COLORADO ACCESS is not responsible for withholding any local,
state and/or federal taxes which may be due with regard to WCAS's relationship with
COLORADO ACCESS. WCAS acknowledges its responsibility to remit any and all taxes
directly to the appropriate taxing authorities.
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I. No Third Party Beneficiary Enforcement. It is expressly understood and
agreed that, with the exception of Paragraph 4B.(a). of this Agreement, enforcement of the terms
and conditions of this Agreement, and all rights of action relating to such enforcement, shall be
strictly reserved to the undersigned parties, and nothing contained in this Agreement shall give or
allow any claim or right of action whatsoever by any other person not included in this
Agreement. It is the express intention of the undersigned parties, that anyone receiving services
or benefits under this Agreement, shall be deemed an incidental beneficiary only.
J. Modification of Agreement. No part of this Agreement, including this
paragraph, may be modified or amended except in writing signed by both parties, but
COLORADO ACCESS may modify or amend this Agreement, effective immediately, when any
State or Federal law, regulation or agency requires COLORADO ACCESS to make the
modification or amendment, by sending written notice to WCAS, pursuant to the notice
provisions of this Agreement.
IN WITNESS WHEREOF,the undersigned have executed this Agreement as of the day
and year first written above.
BOARD OF COUNTY COMMISSIONERS Approved as to Form:
WELD COUNTY, CO I RADO
'am1v
•zfiii� i Ali A
/ F�pl�" 1 . irkmey,r, Chair / Br arker
' eld County Attorney
WaW.4, rigunty er to the o.rs Ap oved-as to Substance:
OR vAdtdr:#5
Deputy Clete o the Board . McCa:•, I rector
Wel. County ' mbulance Service
COLORADO ACCESS I
By: . 0-A ' Z /
Authorized Agent (Signature)
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Authorized Agent (Print)
Title
Date
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APPENDIX A
1. Advance Directive: a written or oral statement made and witnessed in advance of serious
illness or injury setting forth whether the individual wants medical personnel to provide,
withhold or withdraw life-prolonging procedures, or designating another to make such treatment
decisions for that person.
2. Ancillary Provider: a duly licensed physician, hospital, pharmacy, dentist or other
licensed ancillary services provider who has entered into a written Ancillary Provider Agreement
with COLORADO ACCESS, to provide Covered Services to Members.
3. Clean Billing Statement: a complete statement of billing that does not require any
additional information in order for the claim to be processed.
4. Co-payment: the predetermined amount a Member must pay, whether stated as a
percentage or a fixed dollar, to receive a specific service or benefit.
5. Covered Services: medical services within the scope of WCAS's specialty to be
provided to Members and covered under the applicable Prepaid Health Services Plan in which
Member is enrolled. Non-emergent covered services shall be pre-authorized by COLORADO
ACCESS.
6. Department: the Department of Health Care Policy and Financing.
7. Emergency Services: Medically Necessary services that are immediately required
because of unforeseen illness or injury. Such services must be or appear to be needed
immediately to prevent the death of the Member or serious impairment of Member's health.
8. Medically Necessary: appropriate and necessary services determined by COLORADO
ACCESS which are rendered to a Member for any condition requiring, according to accepted
principals of good medical practice, the diagnostic or direct care and treatment of an illness or
injury and are not provided only as a convenience.
9. Member: each individual eligible for coverage and properly enrolled under the
COLORADO ACCESS Plan.
10. Primary Care Provider or PCP: a duly licensed physician who has entered into a
written Primary Care Provider Agreement with COLORADO ACCESS, through which such
physician agrees to provide primary care covered services to Members.
11. Provider Manual: the Provider Manual in effect at the time of execution of the
Agreement, and provided to WCAS prior to execution of the Agreement.
Appendix A
page two
12. Quality Management ("QM"): the program of quality management established by
COLORADO ACCESS to assure the proper level and quality of care is provided including, but
not limited to, COLORADO ACCESS's Provider Manual and Medical Practice Guidelines. The
QM Program outlined in the Provider Manual and Medical Practice Guidelines may be changed
by COLORADO ACCESS upon written notice to WCAS.
13. Utilization Management("UM"): a comprehensive program that promotes and
maintains high quality care for all members through appropriate allocation of medical resources
in the most cost-effective manner. The UM program outlined in the Provider Manual and
Medical Practice Guidelines may be changed by COLORADO ACCESS upon written notice to
WCAS.
APPENDIX B
Colorado Access
FEE SCHEDULE
All payments will be made based upon a completed HCFA 1500 claim form. The clean
claim form should be received within forty-five (45) days of the patient encounter. A clean claim
must include a copy of the referral, if applicable, specialist reports and associated charges.
Should the claim form be received after six (6) months of the patient encounter, COLORADO
ACCESS will not be responsible for payment.
All claims will be paid within forty-five (45) days after receipt of the clean claim form.
WCAS will be paid based upon the following fee schedule:
1. At 90% of the current Medicaid allowable rates.
The Current Medicaid Fee Schedule rates are as follows:
Basic Life Support $74.89
Mileage 1.16 per mile
ALS 117.21
Mileage 1.16 per mile
Ambulance-non Emergency Trans 69.99
Mileage 1.16 per mile
Wheelchair Transportation 11.52 one way
Mileage 0.47 per mile
Oxygen in Transport 10.30 one way
Neonatal Transportation 117.21
Mileage 1.16 per mile
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APPENDIX C
FACILITY & PAYMENT INFORMATION
FACILITY INFORMATION SHEET
List all locations providing services included in this Agreement, and tax identification numbers if
different (use additional sheets as necessary):
Name: Weld County Ambulance Service
Address: 1121 M Street -
City, State, Zip: Greeley, CO 80631
Telephone: (970)353-5700 X3201 Fax: (970)353-5700 X3203
Name:
Address:
City, State, Zip:
Telephone: Fax:
•
Name: -
Address:
City, State, Zip: •
Telephone: Fax:
(Organizations with multiple providers may attach copies of directories with above information noted)
Federal Tax ID Number: 84-6000813
Medicaid Number: 06646038
Medicare Number: 64603
State Tax ID Number: 98-03551
Colorado Dept. of Health Certification Number: -
(Provide copy of Certificate)
Regulatory Agency Certification Name and Number
DO YOU PLAN TO USE A BILLING COMPANY ? YES NO X
MAKE CHECKS PAYABLE TO:
Name: Weld County Ambulance Service
Address: 1121 M Street
City, State, ZIP: Greeley, CO 80631
SUBMIT THE FOLLOWING ADDITIONAL APPLICABLE INFORMATION WITH THIS
CONTRACT:
• General'Liability Insurance Carrier, Declaration of Insurance page detailing coverage type,
limits of coverage and insured name.
• Professional Liability Insurance Carrier, Declaration of Insurance page detailing coverage
type, limits of coverage and insured name.
• Copies of other facility licenses and/or certifications as appropriate
•
•
org 4 95 amb-agr
rev 1.96
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