HomeMy WebLinkAbout950331.tiff RESOLUTION
RE: APPROVE MEDICAID ELECTRONIC DATA INTERCHANGE AGREEMENT BETWEEN
COLORADO DEPARTMENT OF HEALTH CARE POLICY AND FINANCING AND WELD
COUNTY HEALTH DEPARTMENT 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 Medicaid Electronic Data Interchange
Agreement between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Weld County Health Department, and the
Colorado Department of Health Care Policy and Financing, 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 Medicaid Electronic Data Interchange Agreement between the County
of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County,
on behalf of the Weld County Health Department, and the Colorado Department of Health Care
Policy and Financing 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 March, A.D., 1995.
BOARD OF COUNTY COMMISSIONERS
iwi? OUNTY, C L RA 0
ATTEST: ,
0 k
Dale K. Hall, Chairman
Weld County Clerk to the Board
FXCl1SFr]
/� �� g Barb a J. Kirkmey r, Pro-Tem
BY: J�tA/j,I V t-'
Deputy Clerk t he Board 1 7
Geor a E. Baxter
APPRO TO FORM:
Constance L. Harbert /J
unty Attorney /fit . 1 b)j,
W. H. Webster
950331
HL0021
Medicaid Electronic Data Interchange (EDI) Agreement
This agreement is made by and between the Colorado Department of Health Care Policy and Financing,
as the Medicaid Single State Agency for the administration of the Colorado Medical Assistance
Program, herein called "State",
and Weld County Health Department , herein called "Provider".
PROVIDER NAME
It is understood that this agreement is subject to modification, revision or termination due to changes
in federal or state laws and regulations pertaining to Medicaid. 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 material benefits to be derived by Provider, and the undertakings of the
Colorado Medical Assistance Program, Provider agrees;
A. That claims for services provided to eligible Medicaid recipients will be submitted in an
approved electronic format to the Medicaid fiscal agent for the Colorado Medical Assistance
Program, unless hard copy claims submittal is specifically authorized by the Colorado Medical
Assistance Program.
B. To maintain records which fully and accurately disclose the extent of benefits provided to
eligible individuals under this program, in accordance with Colorado Department of Social
Services Manual Volume 8 (8.130). Medical care records shall contain the following
information:
b.1 . Recipient name or other recipient identification on each page of the record.
b.2. Signature and date for each entry in the record (signed and dated by the individual
providing health care). Entries for services provided by an individual under the
supervision of an individual licensed provider and which is billed to the program, shall
be countersigned by the provider rendering the service.
b.3. Diagnoses, assessments or evaluation outcomes.
b.4. The recipient case history and results of oral or physical examinations.
b.5. The plan of treatment or recipient care plan.
b.6. Quantities and dosages of any prescribed drugs ordered and/or administered.
b.7. The results of all diagnostic tests and examinations.
b.8. Any notes indicating the recipient's progress, response to treatment, change in
treatment, or change in diagnosis.
b.9. Copies of consultation reports relating to a particular recipient.
b.10. Dates of hospitalization relating to service provided by a particular provider.
b.1 1 . A copy of the summary of surgical procedures billed to the program by the provider.
C. To furnish the Colorado Medical Assistance Program, or its designee, with such information
as it may request regarding payments claimed for benefits provided under this program.
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Medicaid Electronic Data Interchange (EDI) Agreement
D. To comply with all Federal and State civil and criminal statutes, regulations and rules relating
to the delivery of benefits to eligible individuals and to the submission of claims for such
benefits.
E. To accept as payment in full, amounts paid in accordance with schedules established under
the Colorado Medical Assistance Program and certify that no supplemental charges have been,
or will be, billed to the recipient, except for amounts designated as copayment, and/or amounts
for non-covered items or services, if any, not reimbursable under the Colorado Medical
Assistance Program. To further agree not to bill the recipient for covered items or services
which are permissible for reimbursement under the Program.
F. To assume full legal responsibility for claims submitted to the Colorado Medical Assistance
Program.
G. To submit claims only for those benefits provided by health care personnel meeting the
professional qualifications as established by the State.
H. To make such disclosure of ownership and provide access to medical records and billing
information to the Colorado Medical Assistance Program, or its designee(s), as required by
federal and state laws and regulations.
If, at any time from the date of this agreement, the Colorado Medical Assistance Program
determines that Provider failed to maintain compliance with any state and/or federal laws, rules
and regulations, Provider understands that suspension from participation in the Medical
Assistance Program, and/or subjection to administrative actions authorized through the Medical
Assistance Act may result, together with criminal investigation and prosecution.
J. That the U.S. Department of Health and Human Services, the Colorado Medical Assistance
Program, or the Medicaid Fraud Control Unit, or their designeels), 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
and 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 laws, regulations, and guidelines.
K. That Medicaid payment by electronic funds transfer (EFT) and advisement by deposit notice
or remittance statement represents confirmation by Provider that funds were accepted for
services rendered and billed.
CERTIFICATION STATEMENTS:
1 . Since a certification signature is not possible on electronic claims, in submitting machine
readable claims, I understand that I am certifying that the required provider and patient
signatures, or, where applicable, appropriate signatures on behalf of the patient, and required
physician certifications and recertification (e.g., PRO and CLIA certifications where applicable)
are on file in my office and that anyone who misrepresents or falsifies essential Medicaid claim
information, or causes such misrepresentation or falsification by another, may upon conviction
be subject to fine and imprisonment under state or federal law.
2. CERTIFICATION STATEMENT APPLICABLE TO HARD COPY BILLERS ONLY:
A. I certify that if a claim for payment is not personally signed by me, the signature will
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Medicaid Electronic Data Interchange (EDI) Agreement
be specifically authorized by me and will be the authorized signature' on file with the
fiscal agent. Furthermore, I take full responsibility for the items and/or services
submitted under my Medicaid provider number.
B. If the Provider signing the claim form as the billing provider is not the provider of
service, it is understood that there is an agreement between the Provider and that
person signing the claim that:
1) The Provider has authorized the signature on the claim for services.
2) The Provider has filed with the fiscal agent the authorized signature.
3) The Provider takes full responsibility for the items, charges, or services
submitted under the provider number.
3. I certify that the information submitted for payment of services of claims is true, accurate and
complete. I understand that payment and satisfaction of a claim will be from federal and state
funds, and that any false claims, statements or documents, or concealment of a material fact
will be prosecuted under applicable federal and state law. Payment has not been received or
applied for from any other source, except as may be noted on the claim, or as received from
the recipient in the form of copayment.
4. 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 recipient,
except for any items or services which are not reimbursable under the Colorado Medical
Assistance Program. I agree not to bill the recipient 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.
5. 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 affiliation, 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
his/her handicap, be excused from participation in, be denied the benefits of or be subjected
to discrimination under any program or activity receiving federal financial assistance."
6. I agree to answer questions and to keep such records as are necessary to disclose the nature
and extent of services provided to an individual under the state's Title XIX plan. I will furnish
information regarding such requests for payment on request of the U.S. Department of Health
and Human Services, the Colorado Medical Assistance Program, the Medicaid Fraud Control
Unit, or their representatives. All such records will be maintained for six (6) years unless an
additional retention period is required under state or federal regulations, such as an audit
started before the six (6) year period ended, or in a specific contract with the Provider.
Records will be subject to inspection by any of the above named agencies upon reasonable
notice.
7. I certify that I am currently licensed by the appropriate state licensing agency in which these
services were rendered, and that the items or services for which payment is requested are
medically necessary or covered preventive services.
8. I agree not to disclose any information concerning a Medicaid recipient to any person or
1 Pharmacy providers are prohibited by State regulations to have an authorized signature that is not
a pharmacist's signature, or a signature which is not an original.
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Medicaid Electronic Data Interchange (EDI) Agreement
organization other than the Department of Health and Human Services, the Colorado Medical
Assistance Program,the Medicaid Fraud Control Unit, or their designee(s), without the express
written permission of the Medicaid recipient, or his or her lawful representative.
9. CERTIFICATION STATEMENT APPLICABLE TO PHYSICIANS ONLY:
I certify that the services for which payment is requested were medically necessary, and were
rendered personally by me or rendered by qualified personnel under my direct and personal
supervision as defined by Department of Social Services regulation 10 CCR 2505-10, section
8.201 which states:
"Direct and personal supervision, for purpose of contracting with a Medicaid provider,
shall be defined to mean that a physician shall be physically present on the premises
at the time the treatment is provided by the qualified non-physician provider, unless
otherwise provided in these rules."
10. The Provider and person signing the claim, or submitting electronic claims, understand that
failure to comply with any of the above in a true and accurate manner will result in any
available administrative or criminal action shown available to the Colorado Medical Assistance
Program, the Medicaid Fraud Control Unit or other government agencies. The knowing
submission of false claims, or causing another to submit false claims, may subject the persons
responsible to criminal charges, civil penalties and forfeitures.
I certify that I have read and understand paragraphs 1 through 10 above and that any false claims,
statements, documents, or concealment of material fact may be prosecuted under applicable federal
and state laws.
PROVIDER COLORADO MEDICAL ASSISTANCE PROGRAM
By: 7T1....& t9'
By: t f4v„ ,9��_.,
(Signature) (Signature)
Weld County Board of Commissioners
Name: Weld County, Colorado Name:
Title: Chairman Title:
Date: 03/06/95 Date:
Provider Number(s): 04421095
04005542
01290634
WELD COUNTY HEALTH DEPARTMENT.
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OHN S. PIC E,DIRECTOR 950331
V Atilt mEmoRAnDum n.
While Dale Hall, Chairman
To Board of County Commissioners Date March 3, 1995 C '
COLORADO
From John Pickle, Director, Health Departmea, -
Subject: Agreement for Participation in Automated Medical Payments
System (AMP)
Effective April 3, 1995, Medicaid is mandating all claims be submitted electronically using the
Automated Medical Payments System (AMP). Enclosed for Board approval is an agreement
between the Weld County Health Department and the Colorado Department of Health Care
Policy and Financing as the Medicaid Single State Agency for the administration of the Colorado
Medical Assistance Program. This agreement specifies the responsibilities of WCHD for
participation in the AMP billing system in exchange for financial reimbursement of these
claims.
I recommend your approval of this agreement.
Enclosure
950331
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