HomeMy WebLinkAbout121613_ca13JEFFERSON COUNTY PUBLIC HEALTH Consent Agenda
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615 Sheridan Street 0 Port Townsend o Washington o 98368
www,�effer rig couju�itypk,ubliucheakh .or
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November 14, 2013
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TO: Board of County Commissioners
Philip Morley,, County Administrator
79 ITS'l 111111111111111M 11111 In. ro M a
DATE:
CUBJECT: Agenda Item — Group Provider Agreement for WA Medicaid
beneficiaries with Amerigroup Washington, Inc.; upon signature —
2 year term with annual auto renewal, thereafter; fee for service
STATEMENT OF ISSUE:
Jefferson County Public Health requests Board approval of the Group Provider Agreement for WA Medicaid
beneficiaries with Amerigroup Washington, Inc.; upon signature — 2 year term with annual auto renewal,
thereafter; fee for service
ANALYSIS/ STRATEQ1C, GOAL SjPRO'S and CONS:
This is a re-submittal of this contract. Amerigroup Washington, Inc cannot locate the signed contract that
was sent to them in mid 2012. They have asked that We re-suli it a new contract for signatures. 'Q_ o'l e
This is one of the three managed care contracts that the Washington State Health Care Authority has
assigned to our county to provide care to Medicaid clients and Basic Health members.
This agreement will allow JCPH to bill and collect for clinic services provided to WA Medicaid eligible clients
who have chosen Amerigroup Washington, Inc. as their Managed Care Organization. At present, there are
several clients eligible to receive services such as family planning, immunizations, etc. By becoming a
Preferred Provider with Amerigroup Washington, Inc. we impart a savings to our client in out-of-pocket
deductibles and charges. This plan is a benefit to the client, as they will choose their provider accordingly.
This contract will allow underinsured citizens to receive much needed services.
( ' OMMUM ��( KAITH ENVIRONMENTAII,, HEALTH
DEVELOPIMEWAL. MSAB11 111 F S PUBLIC HEALTH WA F E R QUN, � T Y'
MAIM (360) 385-9400 ALWAYS WORKING IIFOR A SAIFER AND MAft (360) 385-9444
FAX: ( � 3'6 0) 3' c,3 5 94 0 1 HEALT FAX: (360) 379-4487
Consent Agenda
FISCAL .IMPACT COST BENEFIT ANALYSIS:
This is a fee for service contract. Total projected insurance collections for 2013 are $61,838
RECOMMENDATION:
JCPH management request approval of the Group Provider Agreement for WA Medicaid beneficiaries with
Amerigroup Washington, Inc.; upon signature — 2 year term with annual auto renewal, thereafter; fee for
service
REVIEWED BY:
......... . ..
Allip McOe. , County Admins rotor
Mb
iNaime according to W-9 form with d/b/a. Jefferson County d/b/a Jefferson County Public Heafth
Federal I Tax Identification IN urnber: 91-6001322
AMERIGROUP Washington, Inc.
PARTICIPATING PROVIDER AGREEMENT
For Facility and Physician and Allied Health Professional Providers
THIS PARTICIPA'I'l . NG PROVIDER AGREEMENT (this "Agreement") is made by and
between AMER-IGROUP Washington, Inc. ("AMERIGROUP") and the undersigned Provider
("Provider"), effective as of the date of complete execution of this Agreement as evidenced by
the date affixed beneath the authorized signature of AMERIGROUP (the "Effective Date").
RECITALS:
A. AMERIGROUP is authorized to arrange for the provision of managed health care
services to Covered Persons in the State of Washington.
B. Provider is authorized in the State of Washington to provide Covered Services to
Covered Persons.
C. AMERIOROUP desires that Provider provides the Covered Services
contemplated herein to Covered Persons pursuant to the terms and conditions set forth in this
Agreement, consistent with the provisions of 42 CFR 434.6 and Provider desires to provide Such
services.
AGREEMENT:
NOW, THEREFORE, in consideration of the mutual covenants and agreements
contained herein and for other good and valuable consideration, the receipt and sufficiency of
which are hereby acknowledged, AMERIGROUP and Provider agree as follows:
ARTICLE I
DEFINITIONS
The following terms shall have the meanings set forth below with respect to services
furnished tinder the Medicaid Program, and as specifically set forth, the Medicare Program.
Ij Am, "Agency" means a federal, state or local agency, administration, board
or other governing body responsible for the governance or administration of a Program, With
respect to the State of Washington, as used herein, Agency also means the Washington Health
Care Authority ("FICA"),
1.2 Behjvicj[Lfl Itcalth Care Services, "Behavioral Health Care Services" means
services rendered for the treatment of mental health or drug and alcohol conditions.
WA Model Phys & AHID-Facility Agreement
6/12
Name accordmng to W-9 form with d/b/a: Jefferson County d/b/a Jefferson County Pubic Health
FederaP Tax Identification Nurnber: 91-6001322
1.3 CMS. -CMS" means the Center for Medicare & Medicaid Services, an
administrative agency within the United States Department of Health & Human Services
1.4 Clean Claim. "Clean Claim" means a claim that can be processed without
obtaining additional information from the provider of the service or from a third party and has
no defect or impropriety, including any lack of any required substantiating docurnentation, or
particular circumstances requiring special treatment that prevents timely payments from being
made on the claim.
1,5 Covered Person. "Covered Person" means a person who is an eligible Program
beneficiary and who is enrolled as an AMERIGROUP i-nember in accordance with applicable
Program enrollment requirements,
L6 Covered 5je�rvices. "Covered Services" means health care services that I-ICA
determines are covered for enrollees. Those health care services (including Behavioral Flealth
Care Services) that a Covered Person is entitled to receive through AMERIGROUP pursuant to
Regulatory Requirements, and for which an Attachment A is attached hereto setting forth the
Providers' reimbursement under one or more Programs including Medicare.
1.7 Ugi—ble ges. "Eligible Charges" are charges for Covered Services as
submitted by Provider, subject to program eligibility, benefit design, coordination of benefits and
applicable authorizations. Eligible charges are those charges billed by the provider subject to
conditions and requirements which make the service eligible for reimbursement. f"ligibility for
reimbursement of the service is dependent upon application of the following conditions and
requirements: member program eligibility, provider prograrn eligibility, benefit coverage,
authorization requirements, provider manual guidelines, AMERIGROUP administrative, clinical,
and reimbursement policies, and code editing logic. The allowed amount reimbursed for the
eligible charge is based on the applicable fee schedule or contracted/negotiated rate after
application of coinsurance, co-payments, deductibles, and coordination of benefits.
AMERIGROUP will not reimburse providers for items the provider receives free of charge and
items the provider provides to the member free of charge,
1.8 EM,erge Mcdieal C�qndition. "Emergency Medical Condition" means a
D�g�
medical condition manifesting itself by acute symptoms of sufficient severity (including severe
pain) that a prudent layperson, who possesses an average knowledge of health and medicine,
could reasonably expect the absence of Immediate medical attention to result in placing the
health of the individual (or, with respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy, serious impairments of bodily functions, or serious
dysfunction of any bodily organ or part. An Emergency Medical Condition shall not be defined
on the basis of lists of diagnoses or symptoms.
I. E
Lrnergencv Services. "Emergency Services" means inpatient and outpatient
contracted services furnished by a provider qualified to furnish the services needed to evaluate or
WA ModO Phys & AHP-F adfity Agreement - 2-
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Name according to, W-9 form with d/b/a: Jefferson County d/b/a Jeffer5on County Pubtic IHeaith
FederaG Tax ldenLificat[on Number. 91-6001322
stabilize an emergency medical condition (42 CFR 438.114(a)), Otherwise covered health care
services medically necessary to evaluate and treat an emergency medical condition, provided in a
hospital emergency department.
1010 1-11pAA ReguLgtions. "HIPAA Regulations" shall mean those regulations adopted
pursuant to the Health Insurance Portability and Accountability Act of 1996 and codified at Title
4.5 of the Code of Federal Regulations ("CT R,") relating to the privacy and security of protected
health information, and including, without limitation, any amendments or successor laws, rules
or regulations thereto.
1.11 Me& I Nccessary.
(a) L)efinition. "Medically Necessary" means services that are "medically
necessary" as is defined in WAC 182-500-0070. Those services, based upon generally accepted
medical practices in light of the Covered Person's condition at the time of treatment, that are:
(i) Appropriate and consistent with the diagnosis of the treating
provider and the omission of which could adversely affect the Covered Person's medical
condition;
(ii) Compatible with the standards of' acceptable medical practice in
the community;
(iii) Provided in a safe, appropriate, and cost-effective setting given the
nature of the diagnosis and the severity of the symptoms;
(iv) Not provided solely for the convenience of the Covered Person or
the convenience of the provider or hospital;
(v) Not primarily custodial care unless custodial care is a Covered
Service; and
(vi) `there are no other effective and more conservative or substantially
less costly treatment, service and setting available.
(vii) related to the enrollee's ability to achieve age-appropriate growth
and development.
(b) M_qdicare Considerations. Under the Medicare program, "Medically
Necessary" services are health care services that are:
(i) Reasonable and necessary to prevent illnesses or medical
conditions, or provide early screening, interventions, and/or treatments for conditions that cause
suffering or pain, cause physical deformity or limitations in function, threaten to cause or worsen
a handicap, cause illness or infirmity of a Covered Person, or endanger life;
WA Made[ Phys & AHP-Fa(,iiitY Agreement -3 -
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Nairne according to W-9 form wfth cl/bja. Jefferson County d/b/aJefferson County Publk Health
Federal Tax Idenb fication it umber: 91- 6001322
(ii) Provided at appropriate facilities and at the appropriate levels of
care for the treatment of a Covered Person's health conditions;
(iii) Consistent with health care practice guidelines and standards that
are endorsed by professionally recognized health care organizations or governmental agencies;
(iv) Consistent with the diagnoses of the presenting symptoms and
conditions; and
(v) No more intrusive or restrictive than necessary to provide a proper
balance of safety, effectiveness, and efficiency.
1,12 Partiiating Provider. "Participating Provider" means a person, health care
provider, practitioner, or entity, acting within their scope of practice and licensure, with a written
agreement with AMERIGROUP to provide Covered Services to Covered Persons or any other
person or entity that (a) is licensed to provide the health care services such person or entity is
providing tinder the laws of Washington; (b) is party to a participation agreement with
AMERIGROUP to provide Covered Services to Covered Persons, or is an employee or
subcontractor of a Participating Provider and will be furnishing Covered Services hereunder; and
(c) is, if applicable, duly credentialed by AMERK3ROUP in accordance with AMERIGROUP
credentialing, requirernents for the services the Participating Provider provides. The definition of
"Participating Provider" includes., but is not limited to, Provider.
1,13 C Prima y
r ___ �q-reProvider (PCP) means a participating provider who has the
responsibility for supervising, coordinating, and providing primary health care to enrollees,
initiating referrals for specialist care, and maintaining the continuity of enrollee care. PCPs
include, but are not limited to Pediatricians, Family Practitioners, General Practitioners,
Internists, Physician Assistants (under the supervision of a physician), or Advanced Registered
Nurse Practitioners (ARNP), as designated by AMERIGROUP. The definition of PCP is
inclusive of primary care physician as it is used in 42 CFR 438. All Federal requirements
applicable to primary care physicians will also be applicable to primary care providers as the
term is used herein. (a) is credentialed in accordance with AMERIGROUP credentialing
requirements for Primary Care Physicians or Primary Care Providers; (b) provides Primary Care
Services; and (c) practices in the rnedical specialty areas of general practice, internal medicine,
pediatrics, family medicine, or such other medical specialty areas as are specified to provide
Primary Care Services in an applicable Program Contract.
1,14 lrirlar Care Services. "Primary Care Services" means (a) those Covered
Services provided to a Covered Person involving initial and basic primary medical care,
including, but not limited to, the Covered Services specifically identified as primary care
services in an applicable Program Contract, and (b) the supervision and coordination of the
delivery of these Covered Services to a Covered Person.
1,15 1111ggyarn. "'Program" means a Washington Medicaid managed care program
("Medicaid"), a state or local Child Health Insurance Program ("CHIP"), a Medicare Advantage
program ("Medicare"), or any successor prograrns thereto, and such other federal, state or local
WA modei Phys & SHIP -Fad flty Agreement 4 -
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Name a ccording to W-9 form with d/b/a: Jefferson County d/b/aJefferson County PubficHeaftlh
Federal Fax I de, nfifi cation Number: 91-6001322
program related to, or administered in conjunction with, Medicare, Medicaid, or CHIP including,
without limitation, any program providing coverage for eligible family members of CHIP
beneficiaries or persons eligible for coverage Linder both the Medicare and Medicaid Programs,
and for which an Attachment A is incorporated into this Agreement setting forth the Providers'
reimbursement for a respective Program,
1.16 1�rqgLarm ..Contract, "Contract" means the entire written agreement between The
State of Washington Health Care Authority (HCA) and AMERIGROUP, including any Exhibits,
documents, and materials incorporated by reference or any applicable Agency of a jurisdiction,
which governs the delivery of managed health care services to Program beneficiaries.
1.17 Re ulator I.eguiremenis "Regulatory Requirements" means any requirements
imposed by applicable federal, state or local laws, rules, regulations, a Program Contract, or
otherwise imposed by an Agency in connection with the operation of a Program or the
performance required by either party under this Agreement.
ARTICLE 11
AMERIGROUP OBLIGATIONS
2.1 L
deqtjf1cELtion Cards. AMERIGROUP shall issue each Covered Person an
identification card reflecting the Covered Person's name, the Covered Person's selected Primary
Care Physician, the Covered Person's AMERIGROUP identification number, and such other
information as required by an Agency. A sample identification card will be provided upon
request of Provider.
2,2 L)rov�der Manual. AMERIGROUP shall furnish Provider with a "Provider
Manual" referencing the policies and procedures established by AMERIGROUP including,
without limitation, eligibility verification, utilization review, drug utilization, quality assurance,
member grievances, provider grievances, appeals and such other policies and procedures
applicable to AME'RIGROUP and Provider as required by Regulatory Requirements, and to
otherwise effect the delivery of managed health care services to Covered Persons hereunder.
AMERIGROUP shall provide electronic access to its Provider Manual through
AMERIGROUP's website. AMERIGROUP shall provide Provider with at least sixty (60) days
prior notice of any material modifications to such Provider Manual thereafter.
2.3 policies and Procedures. AMERIGROUP shall reference material policies arid
procedures applicable to Provider in the Provider Manual. Notwithstanding the above,
AMERIGROUP's Failure to include a specific policy or procedure in the Provider Manual shall
not limit the applicability of such policy and procedure to Provider; provided that
AMERIGROUP uses its commercially reasonable: efforts to notify Provider of such policy.
AMERIGROUP shall furnish Provider with written notice of any material modifications to such
policies and procedures during the term of this Agreement, and shall respond to Provider
inquiries related to Such policies and procedures in a timely manner. Provider shall comply with
all AMERIGROUP policies and procedures communicated to Provider by AME'RIGROUP,
WA Model PhyS & AHP-Facdity Agre.ernent - 5 -
6/12
Name according to w-9 form with d/b/a: Jeffei's0i" County d/b/a Jefferson County Public Health
Federal Tax Identification Number: 91•6001322
2A R�oqs. AMERIGROUP shall provide to Provider such utilization profiles or
other reports, if any, which AMERIGROUP is required to provide to Provider under Regulatory
Requirements.
2.5 provider LjA,n -, MarketinirVAdverti sing. For the purposes of enrolling and
referring Covered Persons, marketing, complying with Program Contract requirements, reporting
to Agencies, and otherwise carrying out the terms and conditions of this Agreement,
AMERIGROUP shall be entitled to use the name(s), business address(es), and phone number(s)
of Provider including any individual Participating Provider employed by or under contract with
Provider to provide services hereunder. AMERIGROUP shall, and shall be entitled to, use
information related to any such individual Participating Provider's education, specialty,
subspecialty, licensure, certification and hospital affiliation for the purposes described above.
16 CredeqjaIirt - Except as mutually agreed by the parties and as evidenced in
writing by an addendum to this Agreement, AMERIGROUP shall credential Provider and all
Participating Providers providing services hereunder on behalf of Provider pursuant to
AMERIGROUP credentialing criteria applicable to Provider and any such Participating
Providers.
17 the rle o I ene is and I eterminaticrn of overecf Servic es. AMERIGROUP
shall provide Provider with schedules of Covered Services for applicable Programs and will
notify Provider in a timely manner of any material amendments or modifications to such
schedules.
Z. Aff --11 i 4Le--SSc-D LIC—e s -
(a) Covered Services ftirnished to members of certain out -of state entities
affiliated with AMERIGROUP, including, without limitation, other AMERIGROUP
corporations ("Affiliates"), shall be paid in accordance with the rates set forth in this Agreement
or such other rates established by the Affiliate's state Program governing care to out-of-state
members. Such services will be furnished in accordance with the terms and conditions of the
Provider Manual. Notwithstanding the above, for purposes ofthis Section, "Affiliate Services"
shall rnean those services required to be furnished to an Affiliate's members pursuant to the
applicable Program in the state in which the Affiliate is responsible for furnishing services.
(b) AMIRIGROUP shall be responsible for coordinating between Provider
and the applicable Affiliate for any member of an Affiliate that receives services at Provider.
AMERIGROUP shall ensure that the Affiliate adjudicates and pays for services furnished
hereunder in accordance with this Agreement.
(c) Nothing in this Agreement shall be construed to make Provider a
participating provider of any Affiliate, and Provider shall not be identified as such in any
Affiliate directory of participating providers.
(d) Affiliates shall be deemed 'third party beneficiaries of this Section.
WA madel Phys & AHP-Faciflty Agreement -6-
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Name according to W-9 form with d/b/a: Jefferson county d/b/a Jefferson County Public Health
Federate fax Identification Nurnber; 91-6001322
ARTICLE III
PROVIDER OBLIGATIONS
3,1 provider Services. Provider shall provide to Covered Persons those Covered
Services within tile scope of Provider's licenSUrC, expertise, and usual and customary range of
services pursuant to the terms and conditions of this Agreement, and shall be responsible to
AMERIGROUP for its performance hereunder. Provider shall provide to Covered Persons
access to 24 hours a day, 7 days per week urgent and emergency services as required by
Regulatory Requirements. Provider shall release to AMERIGROUP any information necessary
for AMERIGROUP to perform any of its obligations under this Agreement or under the Program
Contract.
3.2 1 �
jeellsure and Accreditation. At all times during the term oaf f this Agreement,
Provider shall (a) maintain in good standing all applicable licenses, certifications and
registrations required for Provider to furnish services hereunder; (b) be a certified Medicare and
certified Medicaid Provider, to the extent required under the Programs; (c) obtain and maintain
accreditation at all times during the term of this Agreement from the applicable nationally
recognized accrediting body, and (d) not be subject to any determination or action that would
adversely impact Provider's license or status as a certified Medicare and Medicaid provider.
Provider shall ensure that each of Provider's employees is duly liccrised, certified or registered as
required under a Program and applicable standards of professional ethics and practice. Provider
shall notify AMERIGROUP within three (3) business days following Provider's receipt of ally
notice of any restrictions upon, or any suspension or loss of, any licensure, certification or
registration, or receipt of any notice of any restrictions, suspension or revocation of such
accreditation required hereunder. Provider shall submit to AMERIGROUP evidence of
Provider's satisfaction of the requirements set forth in this section upon AMERIGROUPs
reasonable request. Subject to Regulatory Requirements, AMERIGROUP has the right to
immediately terminate this Agreement upon the expiration, surrender, revocation, restriction, or
suspension of such accreditation. Provider shall obtain and maintain a National Provider
Identification number ("NPI") as required by applicable law,
3.3 Covered Person Verification. Provider shall establish a Covered Person's
eligibility for services prior to rendering services, except in the case of an Emergency Medical
Condition where such verification may be impractical. In the case of an Emergency Medical
Condition, Provider shall establish a Covered Person's eligibility as soon as reasonably practical.
AMERIGROUP shall provide a system for Providers to contact AMERIGROUP to verify,
Covered Person eligibility 24 hours a day, 7 days per week. Nothing contained in this
Agreement shall, or shall be construed to, require advance notice, coverage verification, or pre-
authorization for emergency room services provided in accordance with the federal Emergency
Medical Treatment and Active Labor Act ('WrALA") prior to Provider's rendering such
services. Nothing contained in a participating provider agreement may have tile effect of
modifying benefits, terms, or conditions contained in the Program Contract. In the event of any
conflict between the participating provider agreement and the Program Contract, the benefits,
terms, and conditions of the Program Contract shall govern with respect to Covered Services
provided to Covered Persons.
WA Model Phys & AHP-Facility Agreement ..7
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Name according to W-9 fOM with d/b/a: Jefferson County d/b/a Jefferson County Pubfic Heafth
Federal Tax ldentlfication Nwnber; 91-6001322
3.4 Rrovider R csta nsibilZty. AMERIGROUP shall not be liable for, nor will it
exercise control or direction over, the manner or method by which Provider provides services to
Covered Persons, Provider shall be solely responsible for all medical advice and services
provided by Provider to Covered Persons, Provider acknowledges and agrees that
AMERIGROUP may deny payment for provider services rendered to a Covered Person which it
determines are not Medically Necessary, are not Covered Services pursuant to an applicable
Program Contract, or are not otherwise provided in accordance with this Agreement. Neither
such a denial nor any action taken by AMERIGROUP pursuant to a utilization review, referral,
or discharge planning program shall operate to modify Provider's obligation to provide
appropriate services to a Covered Person under applicable law and any code of professional
responsibility. Nothing in this Agreement shall be construed as prohibiting any Participating
Provider from discussing treatment or non-treatment options with Covered Persons irrespective
of whether such treatment option-, are Covered Services.
3.5 Qgordinated and Managed Care. Provider shall participate in AMERIGROUP
systems designed to facilitate the coordination of health care services. Subject to medical
judgment, patient care interests, and a patient's express instructions, and recognizing that the
level of Covered Services provided by Provider may be affected by the Provider's scope of
services, Provider shall report clinical encounter data as required by such systems, and shall
obtain all required Covered Person consents or authorizations necessary for Provider to report
such clinical encounter data to AMERIGROUP.
3,6 Provider agrees to provide access to AMERIGROUP
employees to review Covered Persons' medical records and perform on-site concurrent review
during normal business hours. AMERIGROUP employees will cooperate with the requirements
of the Provider while on Provider's premises. During any such on-site concurrent review,
Provider shall provide AMERIGROUP with access to a telephone and appropriate work space to
conduct the review.
3.7 C :omp iance it h—Credentialin _ Utilizaton "g--g—ent ualit Ass
Qrie Lane & gordi.nLation of Benefits Third-.Partv Liability and other Rules, ,RqgUj.gtions, Policies
and Procedures. Provider shall comply and cooperate with all AMERIGROUP and Regulatory
Requirements related to credentialing, utilization management, quality assurance, grievances,
coordination of benefits and third party liability. Provider shall comply with the terms of the
Provider Manual, Provider shall comply with ancillary surety bond requirernent (Section
4708(d) of the Balanced Budget Act of 1997).
3.8 —Insurance CQ La&-
(a) Professional Liability. At all times during the term of this Agreement,
Provider shall maintain professional liability insurance, including maintaining such tail or prior
acts coverage necessary to avoid any gap in coverage for claims arising from incidents occurring
during the term of this Agreement. Such insurance shall (i) be obtained from a carrier authorized
to conduct business in the jurisdiction in which Provider operates; (ii) maintain minirrium policy
limits equal to $5,000,000:00 per occurrence and $ 10,000,000,00 in the aggregate for acute care
hospitals and $1,000,000.00 per occurrence and $3,000,000.00 in the aggregate for other
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Marne according to w-9 form with d/b/aw Jefferson County d/b/a Jefferson County Public Health
Pederal 'Tax Identification Number: 91-6001322
providers; and (iii) include coverage for the professional acts and omissions of Provider and any
employee, agent or other person for whose acts or ornissions Provider is responsible.
(b) (,I'enerql Liability. At all times during the term of this Agreement,
Provider shall maintain general comprehensive liability insurance from a carrier authorized to
conduct business in the jurisdiction in which Provider operates, in arnounts required under
Regulatory Requirements. Said insurance shall cover Provider's premises, insuring Provider
against any claim of loss, liability, or damage caused by or arising out of the condition or alleged
condition of said premises, or the furniture, fixtures, appliances, or equipment located therein,
together with the standard liability protection against any loss, liability or damage resulting firorn
the operation of a motor vehicle by Provider, Provider's employees or agents.
(c) Workers Compensation, Provider shall maintain workers' compensation
insurance for Provider's employees. Said insurance shall be obtained from a carrier authorized
to conduct business in the jurisdiction in which Provider operates and shall provide such limits of
coverage as required by Regulatory Requirements.
(d) Lvidence of Insurance. Provider shall provide AMERIGROUP with
evidence of Provider's compliance with the foregoing insurance requirements as reasonably
requested by AMERIGROUP from time to time during the term of this Agreement, but in no
event less than annually. Provider shall provide AMERIGROUP with at least thirty (30) days
prior written notice of any cancellation or non-renewal of any required coverage or any reduction
in the amount of Provider's coverage, and shall secure replacement coverage meeting the
requirements hereunder so as to ensure no lapse in coverage. Provider shall furnish
AMERIGROUP with a certificate of insurance evidencing such replacement coverage. Provider
shall also furnish a certificate of insurance to a requesting Agency upon request. Provider may
maintain coverage hereunder through a self-funded insurance plan, provided that Provider
maintains actuarially sound reserves related to such self-funded plan and provides to
AMI,"RIGROUP on a semi-annual basis an opinion letter from an independent actuarial firm or
other proof reasonably acceptable to AMERIGROUP attesting to the financial adequacy of such
reserves.
3,9 Contracted..._2.rovider Reqqiregigfljs. Unless otherwise approved by
AMERIGROUP, Provider and its employees shall perform all the services required hereunder
directly and not pursuant to any subcontract between Provider and any other person or entity (a
"Contracted Provider"). In the event that any portion of the services that Provider is responsible
for hereunder are performed for or on behalf ol'Provider by a Contracted Provider, Provider shall
be responsible for ensuring that such Contracted Provider furnishes such services in compliance
with all of Provider's obligations under this Agreement and in accordance with WAC 284-43-
300, including, without [imitation, maintaining required insurance, and holding Covered Persons
harmless for the cost of any services or supplies provided by Contracted Providers to such
Covered Persons, This section shall not preclude Provider from using contract nursing services
or obtaining locums tenens coverage for Participating Physicians that are on temporary leave.
3,10
WA iMo dfq Phys & AW)-Facflity Agreernerit
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Name according to W-9 form with cl/b/a: Jefferson County d/b/a Jefff!rson County Public HealOn
Federal Tax Identification Nurnber: '91-600132.2
(a) The parties acknowledge and agree that all the following information is
proprietary: AMERIGROUP's quality assurance, utilization management, risk management .and
peer review programs; AMERIGROUPs credentialing procedures; this Agreement, including the
rates of reimbursement payable under this Agreement; AMERIGROUP's Provider Manual;
information related to AMERIGROUP programs, policies, protocols and procedures, and all
information otherwise furnished to Provider by AMERIGROUP as a result of this Agreement.
The parties agree not to use such proprietary information except for the purpose of carrying out
their obligations under this Agreement. Neither party shall disclose any proprietary information
to any person or entity without the other party's express written consent except to the extent such
information is available in the public domain or was acquired by such party from a third party
not bound to preserve the confidentiality of such information, or unless required by law.
(b) Provider and AMERIGROUP shall each treat all information which is
obtained through its respective performance tinder the Agreement as confidential information to
the extent that confidential treatment is required Linder applicable law and regulations, including
without limitation 42 C.17K §422,118 and 45 C.F.R. Parts 160 and 164, as may be arnended
from time to time, and shall not use any information so obtained in any manner except as
necessary to the proper discharge of its obligations and securing of its rights hereunder. Provider
and AMERIGROUP shall each have a system in effect to protect all records and all other
documents deemed confidential by law which are maintained in connection with the respective
activities of Provider or AMERIGROUP and performed in connection with this Agreement. Any
disclosure or transfer of confidential information by Provider or AMERIGROUP will be in
accordance with applicable law.
3,11 Rep.Le
,enj,qtions and Warraq!i.es..
(a) Provider Status, Provider hereby represents and warrants that Provider: (i)
has the power and authority to enter into this Agreement; (ii) is legally organized and operated to
provide the services contemplated hereunder; (iii) is not in violation of any ficensure or
accreditation requirement applicable to Provider under law, Program Contract or Agency rules;
(iv) is in good standing with IICA; (v) has not been convicted of bribery or attempted bribery of
any official or employee of the Jurisdiction in which Provider operates, nor made an admission of
guilt of such conduct which is a matter of record; (vi) is capable of providing all data related to
the services provided hereunder in a timely manner as reasonably required by AMERIGROUP to
satisfy Regulatory Requirements, including, without limitation, data required under the Health
Employer Data and Information Set and National Committee for 'Quality Assurance
requirements; and (vii) qualifies as a participating provider in all Programs in accordance with
the applicable Regulatory Requirements.
(b) provider _Inforivation and ._[Loeumcntation. Provider represents and
warrants that all information provided by Provider to AMERIGROUP, including Without
lirnitation, information relating to insurance coverage, quality assurance, credentialing, change of
ownership of Provider and availability of' medical care by Provider to Covered Persons, is true
and correct as of the date such information is furnished, and Provider is unaware of any
undisclosed facts or circumstances that would make such information inaccurate or misleading.
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Provider shall provide AMERIGROUP with written notice of any changes to such information
within five (5) business days of such change.
(c) AD2gdgEgqp__a!q!1Ls. Amerigroup hereby represents and warrants that
Amerigroup: (i) has the power and authority to enter into this Agreement; (ii) is not in violation
of any licensure or accreditation requirement applicable to Amerigroup under Regulatory
Requirements; (iii) has not been convicted of bribery or attempted bribery of any official or
ernployee of the jurisdiction in which Amerigroup operates, nor rnade an admission of guilt of
such conduct which is a matter of record; (iv) qualifies to participate in a Program as of the date
on which Provider may furnish Covered Services hereunder for such Program; and (v) is not, to
Arnerigroup's best knowledge, the subject of an inquiry or investigation that Could foreseeably
result in Arnerigroup failing to comply with the representations in subsections (i) — (iv) above.
3.12 Re orti� err l rand and . Provider shall cooperate with AMERIGROUP's
anti-fraud compliance program. If Provider identifies any actual or suspected fraud, abuse or
misconduct in connection with the services rendered hereunder, in violation of state or federal
law, Provider immediately shall report such activity directly to AMERIGROUP in accordance
with the Provider Manual, Provider shall comply with FICA approved fraud and abuse policies
and procedures.
3.13 C, o nrmac �e Nyi - th Law. Without limiting the applicability of, any other sanctions
and penalties that may be applicable for Provider's failure to conform with such federal, state
and local laws, rules and regulations, Provider acknowledges and agrees that, in connection with
the Medicare Program, Provider's failure to report potential fraud or abuse to CMS may result in
sanctions, cancellation of contract, or exclusion from participation in the Medicare Program.
Provider agrees to comply with all state and federal laws, rules arid regulations that apply to all
persons receiving state and Federal funds, including without limitation, all applicable Medicare
laws, rules and regulations andall CMS instructions.
3,14 Provision (Lf_N.2.n-Coyered Services. Except in the case of an Emergency Medical
Condition, prior to the provision of any services to a Covered person that are not Covered
Services, Provider (a) shall advise the Covered Person, in writing, (i) of the nature of the service;
(ii) that the service is not a Covered Service for which compensation is payable hereunder; and
(iii) that the Covered Person will be responsible for paying for the service; and (b) shall
otherwise comply with all Regulatory Requirements related to the provision of non-covered
services to Covered Persons.
ARTICLE IV
REIMBURSEMENT
4.1 Clajms_5,_ub . Except to the extent Provider is compensated on a capitation
basis under this Agreement, Provider shall submit claims on either a current CMS-1 500 claim
form for professional claims or a CMS-1450 claim form For institutional claims (or successor
forms), or the electronic equivalent in the manner and to the location described in the Provider
Manual, Provider is encouraged to submit claims information through electronic data
interchange (EDI) that allows for automated processing and adjudication of claims. As
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Name according to w-9 form withi cl/b/a: Jefferson County d/b/a Jefferson County Pubflc iHealth
Federal Tax Wentificadon Number: 91-6001322
AMERIGROUP continues to develop electronic interface systems for registration, eligibility and
benefit verification and claims processing, Provider will use such electronic interface systems.
Provider must use HIPAA compliant billing codes when billing or submitting encounter
data. This applies to both electronic and paper claims. When billing codes are updated, Provider
is required to use appropriate replacement codes for submitted claims for Covered Services. In
its discretion, AMERIGROUP may amend the Agreement as it deems necessary to clarify
changes to standard billing codes. Regardless of whether AMERIGROUP so amends the
Agreement, AMERIGROUP shall not pay any claims submitted using non-compliant billing
codes.
Clainis must be submitted within one hundred and eighty (180) days following the date
service is rendered. Claims not received by AME.RIGROUP from Provider within such period
may be denied payment. AMERIGROUP will not deny Clean Claims for payment solely due to
these claims being received after one hundred and eighty (180) days from the date services were
rendered in the event that Provider was unable to determine that the patient was an
AMERIGROUP Covered Person, and where Provider timely filed such claim with another
payor. In such event, Provider shall have one hundred and eighty (180) days to resubmit such
claim to AMERIGROUP from the date Provider receives a denial from the payor to which
Provider originally submitted the claim. Such submission shall include proof of timely filing, and
denial by, such other payor.
42 ReimbLj[senj,ent. As payment in full for Covered Services provided to Covered
Persons hereunder, AMERIGROUP shall pay to Provider the reimbursement specifically set
forth in Attachment A. Reimbursement for Clean Claims shall be made in accordance with all
prompt pay requirements as established under applicable law. Ninety-five percent (95%) of the
monthly volume of clean claims shall be paid within thirty (30) days of receipt by
AMERIGROUP and ninety-five percent (95%) of the nnonthly volume of all claims shall be paid
or denied within sixty (60) days of receipt and ninety-nine percent (99%) within (90) calendar
days of receipt by AMERIGROUP, except as agreed to in writing by the parties on a claim-by-
'claim basis. Provider agrees to accept payments or appropriate denials made in accordance with
this Agreement as payment in full for all Covered Services provided to Covered Persons.
Provider shall be responsible for collecting co- payments from Covered Persons to the extent
required by Regulatory Requirements.
With respect to Medicaid Covered Services, AMERIGROUP shall pay Provider interest
in accordance with WAC 284-43-321(2)(4) on the unpaid portion of Medicaid Clean Claims not
adjudicated within such period as required under applicable prompt pay requirements. With
respect to Medicare Covered Services, AMERIGROUP shall pay Provider interest at a rate equal
to the CMS interest rate in effect at the time of such charge. AMERIGROUP will update the
CMS interest rate applicable to this Agreement on a prospective basis within thirty (30) days
following its publication in the Federal Register.
AMERIGROUP reserves the right to conduct chart review upon reasonable notice to
Provider in order to determine the appropriateness of services and/or charges on a specific claim.
In accordance with WAC 284-43-324(3), Provider shall be granted similar rights to review
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AMERIGROUP denials of specific clainns. AMERIGROUP reserves the right to use a code-
editing software to determine which services are considered part of, incidental to, or inclusive of
the primary procedure.
4.3 imitation tion Qf CQp rkct�Ld Providers- Encounter irements. If Provider is
___Rjt�j_ _L _!Ll)ata Re
compensated for services provided hereunder on a capitated basis, Provider shall:
(a) Arrange and coordinate all capitated Covered Services for Covered
Persons assigned to Provider or one of Provider's Participating Physicians for such capitated
Covered Services;
(b) Accept the capitation payment payable hereunder as payment in full for all
such capitated Covered Services provided to such Covered Persons; and
(c) Timely submit complete encounter data for capitated services rendered to
Covered Persons, including, without limitation, statistical and descriptive medical, diagnostic
and patient data for Covered Services rendered to Covered Persons, and reporting requirements
included in applicable Program Contracts. Provider shall completely and accurately report
encounter data to AMERIGROUP. Provider shall ensure that it has the capacity to submit all
required data to enable AMERIGROUP to meet the reporting requirements, in the Encounter
Data Transaction Guide published by HCA.
(d) If Provider is not compensated on a capitation basis, the Provider shall be
compensated as stated in Section 4.2 above.
4A Einarjciajlncentives. No provision in this Agreement shall, or shall be construed
to, create any incentive, financial or otherwise, for Provider to withhold Medically Necessary
services.
4.5 I�ecoyerics from Third Parties. Provider acknowledges and agrees that claims
payments made by AMEN. GROUP pursuant to Program requirements are subject to Program
requirements regarding third party liability. Provider shall cooperate with AMERIGROUP's
policies and procedures related to third party liability recovery in the event claims for services
rendered by Provider to a Covered Person are related to an illness or injjury for which a third
party may be liable, including, without lin►itation, claims that may be covered by automobile
insurance, workers' compensation coverage, other health insurance, or otherwise give rise to a
claim for third party liability, coordination of benefits or subrogation (to the extent permitted by
Regulatory Requirements). Provider shall take all reasonable actions required by
AME'RI(MOUP to assist AN4ER.IGR.OUP in obtaining such recoveries, including executing any
appropriate documents reasonably requested by AMERIGROUP to enforce Such claims or to
assign any payments to AMERIGROUP, However Provider and AMERIGROUP shall riot
refuse or reduce services provided under this agreement solely due to the existence of similar
benefits under any other health care contract. In addition AMERIGROUP shall pay claims for
prenatal care and preventive pediatric care and shall seek reimbursement from such third parties.
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4.6 g i ht of RefundllRe oast flr Additional Pa meats, AMER-IGROUP shall be
entitled to request a refund in an amount equal to any overpayments made by AMERIGROUP to
Provider in accordance with RCW 48.43.600. Provider shall make requests for additional
payments from AMERIGROUP only in accordance with RCW 48.43.605.
ARMCLE V
PROVISIONS APPLICABLE TO PHYSICIANS AND
ALLIED HEALTH PROFESSIONALS AND FACILITY PROVIDERS
5.1 prjmqry_f,Gire Provider Services. If Provider is furnishing Primary Care Services
under this Agreement, Provider shall, and shall cause the Primary Care Providers employed by or
under contract with Provider to, accept as patients all Covered Persons who are eligible to
receive their Primary Care Services from Provider or a Primary Care Provider employed by or
under contract with Provider. Provider further agrees to provide, or to arrange for the provision
of, appropriate Primary Care Services to such Covered Persons. Provider and any Primary Care
Providers employed by or under contract with Provider, shall refer Covered Persons to Specialist
Physicians only in accordance with procedures established by AMERIGROUP.
5.2 512g6AI.ist Physician Services. If Provider is furnishing Specialist Physician
services under this Agreement, Provider, and the Specialist Physicians employed by or under
contract with Provider, shall accept as patients all Covered Persons who are referred by Primary
Care Providers to Provider. Provider shall provide, or arrange for the provision of, appropriate
Specialist Physician Covered Services (as may be more specifically described in Attachment A
to this Agreement). Provider and any Specialist Physicians employed by or under contract with
Provider, shall refer Covered Persons to other Specialist Physicians only in accordance with
procedures established by AMERIGROUP.
S. F I os
p a
.ital Affiliatioi2- nd Privileges. Provider, in the case of a solo provider, or
any providers employed by or under contract with Provider, in the case of a group provider, shall
maintain in effect privileges to practice at one or more Participating Hospitals, Provider shall
immediately notify AMERIGROUP in the event any such hospital privileges are revoked,
limited, surrendered, or suspended at any hospital or health care facility.
5.4. [lartici at ne Provider Requirements, If Provider is a group provider, Provider
shall cause all Participating Providers employed by or under contract with Provider to comply
with all terms and conditions of this Agreement. Notwithstanding the foregoing, Provider
acknowledges and agrees that AMERIGROUP is not obligated to accept as Participating
Providers all providers employed by or under contract with Provider.
S.S. �F�ederall w Qcalif q�d Health Centers. If Provider is a federally qualified health
center ("I'l)HU) or a rural health center ("RI-IC"), as defined tinder applicable federal law,
Provider shall comply with all requirements related to I'QUICs and RI-ICs under Regulatory
Requirements including, without limitation, compliance with the service quality standards
required In connection with current and future clinical quality reporting methods that are
applicable to FQHCs and administered by federal oversight agencies.
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5.6. Last- 'Stabilization, Provider shall comply with all applicable law related to the
post-stabilization care of a Covered Person after an Emergency Medical Condition has been
stabilized.
5.7. AutoMLitic '[erminatio.DLAutomatic Exclusion.
(a) 6-utomatic 'I°ertj�JnAtion. If Provider is an individual Provider, in addition
to the other termination provisions set forth in this Agreement, this Agreement shall
automatically and immediately terminate upon the expiration, surrender, revocation or restriction
of Provider's medical staff privileges at any one or more Participating Hospitals or if Provider
fails to maintain active staff privileges with respect to at least one (I ) Participating Hospital.
If Provider is a group medical practice, in addition to the other termination
provisions set forth in this Agreement, this Agreement shall automatically and immediately
terminate only with regard to the individual Participating Provider who is subject to the
expiration, Surrender, revocation, restriction or suspension of the Provider's medical staff
privileges at any one or more Participating Hospitals, or if Provider fails to maintain active staff
privileges with respect to at least one Participating Hospital,
(b) Automatic Exclusion. If Provider is a group provider, then upon the
occurrence of any of the actions described in subparagraph (a) above related to the medical staff
privileges of an individual Participating Provider employed by or contracted with Provider,
AMERIGROUP shall be entitled to exclude such Participating Provider from participation under
this Agreement.
5.8, Lxclusion.. of Individual Participating PrDviders. Notwithstanding any other
provision contained in this Agreement, AMERIGROUP shall be entitled to exclude frorn
participation under this Agreement an individual Participating Provider employed by or
contracted with Provider, for any of the reasons included in, and in accordance with the terms
and conditions of, the termination provisions otherwise included in the Agreement. In the event
of such exclusion, this Agreement shall continue in full force and effect as to all other
Participating Providers employed by or contracted with Provider who are not so excluded,
5.9 sicians.. In the event any
Specialist Physicians employed by or under contract with Provider are excluded from
participation under this Agreement, or in the event that Provider is a Specialist Physician, if this
Agreement is terminated for any reason, AMERIGROUP shall notify all affected Covered
Persons under treatment by such Specialist Physician of such termination prior to the effective
date of such termination.
5,10 Provider's Obligations in Case of Emergency Medica..L.-Condition Affecting
Coveredl'ersori.
(a) Provider shall render timely and appropriate Medically Necessary services
to treat an Emergency Medical Condition affecting a Covered Person, and shall comply with all
applicable law related to the post - stabilization care of a Covered Person after an Emergency
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Medical Condition has been stabilized. Provider shall use its best efforts to notify
AMERIGROUP at the time of eligibility verification or by the end of the next business day after
admission and identification of a Covered Person as an inpatient, or after rendition of emergency
outpatient Covered Services to a Covered Person, Notwithstanding any provision contained in
this Agreement, no notification to, or coverage verification or pre - authorization from,
AMERIGROUP is required prior to Provider rendering Emergency Services to a Covered
Person.
(b) If Emergency Services are required for an Emergency Medical Condition
affecting a Covered Person and such Covered Person's condition cannot be treated at Provider's
facilities, or if no Participating Specialist Physician with hospital privileges at Provider's facility
is available to treat the Covered Person at Provider's facility, Provider shall arrange for the
services of an alternate Participating Hospital, or, as applicable, the services of an alternate
Participating Specialist Physician; provided, however, that in the event obtaining the services of
an alternate Participating Hospital or an alternate Participating Specialist Physician is
irlipractical, Provider shall arrange for the services by an appropriate non-participating hospital
or, as applicable, an appropriate non-participating specialist physician.
5.11 Cl rrn Subsissi n for Facilities. In addition to the other requirements described
in this Agreement related to Provider's claim submission, for inpatient lengths of stay in excess
of thirty (30) days, Provider shall provide AMERIGROUP with interim claims within ten (10)
days after the end of the initial thirty (30) day period or any successive thirty (30) day period
thereafter.
5.12 p�hsjcian Privileges. SubJect to Provider's medical staff' bylaws, Provider shall
grant admitting and a ten trig privileges to AMERIGROUP Participating Physicians who satisfy
Provider's credentialing criteria.
ARTICLE VI
COMPLIANCE WITH REGULATORY REQUIREMENTS
6.1 C om . AMERIGROUP and Provider shall
each comply with all applicable Regulatory Requirements related to this Agreement. The failure
of this Agreement to expressly reference a Regulatory Requirement applicable to either party in
connection with their duties and responsibilities hereunder shall in no way limit such party's
obligation to comply with such Regulatory Requirement.
6.2 fold Ijarnilq_ss. Provider agrees to abide by the provisions of WAC 182-502-
0 160, and agrees that in no event, including, but not I irnited to non-payment by AMERIGROUP,
AMERIGROUP insolvency, or breach of this Agreement, shall Provider bill, charge, collect a
deposit frorn, seek compensation, remuneration, or reimbursement from or have any recourse
against a Covered Person, any person acting on behalf of a Covered Person, or HCA for services
provided pursuant to this Agreement. This provision shall not prohibit collection of nominal
cost-sharing or supplemental charges made in accordance with the terms of applicable Program
Contracts or Agency requirements, Provider further agrees that this section shall survive the
termination of this Agreerneitt regardless of the cause giving rise to such termination and shall be
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Name accordiingtoW-9form with d/b/a: Jefferson County d/b/a Jefferson County Public Health
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construed to be for the benefit of Covered Person, and that this provision supersedes any oral or
written contrary agreement now existing or hereafter entered into between Provider and a
Covered Person or persons acting on such Covered Person's behalf. Provider agrees and
understands that willfully collecting or attempting to collect an amount from a covered person
knowing that collection to be in violation of the participating provider or facility contract
constitutes a class C felony under RC W 48.80.030(5). Provider agrees, in the event of
AMERIGROUP's insolvency, to continue to provide the services promised in this Agreement to
Covered Persons of AMERIGROUP for the duration of the period for which premiums on behalf
of the Covered Person were paid to provider or until the Covered Person's discharge frorn
inpatient facilities, whichever time is greater. Notwithstanding any other provision of this
Agreement, nothing in this Agreement shall be construed to modify the rights and benefits
contained in the Covered Person's health plan. Provider may not bill the Covered Person for
Covered Services (except for deductibles, copayments, or coinsurance) where AMERIGROUP
denies payments because the provider has failed to comply with the terms or conditions of this
Agreement. Provider further agrees (i) that the provisions of WAC 284-43-320(a), (b), (c), and
(d) shall survive termination of this contract regardless of the cause giving rise to termination
and shall be construed to be for the benefit of provider's Covered Persons, and (ii) that this
provision supersedes any oral or written contrary agreement now existing or hereafter entered
into between provider and Covered Persons or persons acting on their behalf'. If provider
agreements with other providers who agree to provide Covered Services to Covered Persons of
AMERIGROUP with the expectation of receiving payment directly or indirectly from.
AMERIGROUP, such providers must agree to abide by the provisions of WAC 284-43-320 (a),
(b),, (c), (d), and (e).
Documents, procedures, and other administrative policies and programs referenced in the
Program Contract must be available for review by the Provider prior to contracting, Providers
must be given reasonable notice of not less than sixty (60) days of changes that affect provider
compensation and that affect health care service delivery unless changes to federal or state law or
regulations make such advance notice impossible, in which case notice shall be provided as soon
as possible.
63 compliance with- Program Contract. Nothing in this Agreement shall be
construed to terminate or reduce the legal responsibility of AMERIGROUP to state Agency to
ensure that all activities under Program Contract are carried out. AMERIGROUP shall afford
Provider access to all necessary training and information to enable Provider to carry Out its
responsibilities tinder the Program Contract.
6.4 Medic-are mitations of Billin .
(a) in connection with the Medicare Program, except for costs associated with
non-Covered Services provided to a Covered Person, applicable co-payments and deductibles as
permitted under the Medicare Program and set forth in the AMERIGROUP Provider Manual or
in the schedule of benefits for the Medicare Program are the only amounts that Provider may
collect from a Medicare-eligible Covered Person in connection with Covered Services. Provider
acknowledges that 'Medicaid cost-sharing requirements may preclude Provider's collection of co-
payments or deductibles from dual eligible Medicare and Medicaid Covered Persons.
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(b) Provider shall be responsible for collecting any applicable Medicare
Program co-payments or deductibles at the time of service in accordance with the policies and
procedures set forth in the AMERIGROUP Provider Manual.
(c) Provider understands that if Provider initiates any actions to collect
payment from any Medicare-eligible Covered Person over and above allowable co-payments,
excluding payment for services not covered under the Medicare Program, AMERIGROUP will
initiate and maintain such necessary action to stop Provider or Provider's employee, agent,
assign, trustee, or successor in interest from maintaining such action against such Medicare-
eligible Covered Person.
(d) Covered Persons eligible for both Medicare and Medicaid will not be held
liable for Medicare Part A and B cost sharing when the State of Washington is responsible for
paying such amounts. AMERIGROUP will not impose cost-sharing that exceeds the amount of
cost-sharing that would be permitted with respect to the member under title XIX if the member
were not enrolled in such a plan. The provider will accept AMERIGROUP's payment as
payment in (till or bill the appropriate State source, as appropriate.
(e) Lx�cLjtive Order 13496. This provision is applicable to Providers who
participate in AMERIGROUP's Medicare program under Medicare Parts C and D and receive at
least $10,000 or more in payments from such AMERIGROUP Medicare program. Provider shall
comply with the requirements of Executive Order 13496, 29 CFR 471, Appendix A to Subpart
A.
6,5 Appoirltment Waitj Provider shall offer hours of operation that are no
less than the hours of operation offered to patients with other insurance coverage, including but
not limited to commercial health plans. If Provider is a primary care physician, Provider is
encouraged to offer after-hours office care to Covered Persons on evenings and weekends.
Provider agrees that it will provide for regular monitoring of timely access and corrective action
by AMERIGROUP if Provider fails to comply with the appointment wait time standards as
stated in 42 CFR 438.206(c)(1).. Provider shall comply with 42 CFR §438.206(c)(1). Provider
shall comply with appointment standards that are no longer than the following: (a) Transitional
healthcare services by a primary care provider shall be available for clinical assessment and care
planning within seven (7) calendar days of discharge from inpatient or institutional care for
physical or behavioral health disorders or discharge from a substance use disorder treatment
program. (b) Transitional healthcare services by a home care nurse or home care registered
counselor within seven (7) calendar days of discharge from inpatient or institutional care for
physical or behavioral health disorders or discharge from a substance use disorder treatment
program, if ordered by the enrollee's primary care provider or as part of the discharge plan. (c)
Non - symptomatic (i.e., preventive care) office visits shall be available from the Covered
Person's PCP or another provider within thirty (30) calendar days. A non - symptomatic office
visit may include, but is riot limited to, well/preventive care such as physical exarn i nat ions,
annual gynecological examinations, or child and adult immunizations. (d) Non-urgent,
symptomatic (i.e,, routine care) office visits shall be available from the Covered Person's PCP or
another provider within ten (10) calendar days. A non-urgent, symptomatic office visit is
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associated with the presentation of medical signs not requiring immediate attention. (e) Urgent,
symptomatic office visits shall be available from the Covered Person's PCP or another provider
within forty -eight (48) hours. An urgent, symptomatic visit is associated with the presentation of
medical signs that require immediate attention, but are not life threatening. (f) Emergency
medical care shall be available twenty-four (24) hours per day, seven (7) days per week.
6.6 Non -Qiscri - on .. Provider shall abide by the federal Civil Rights Act of 1964,
the Federal Rehabilitation Act of 1973, and all other applicable statutes, regulations and orders
(including, without limitation, Executive Orders 11.246 and 11375, "Equal Employment
Opportunities") as amended, and any and all successor statutes, regulations and related orders..
Provider shall not exclude any Covered Person frorn participation in any aid, care, service or
other benefit, or deny any Covered Person such services on the grounds of race, color, national
origin, sex, age, disability, political belief's or religion. Provider shall not subject any Covered
Person to discrimination due to such Covered Person's status as a Program Contract beneficiary.
AMERIGROUP is responsible for ensuring that providers furnish Covered Services to Covered
Persons without regard to the Covered Person's enrollment in the plan as a private purchaser of
the plan or as a participant in publicly financed programs of health care services. ..Phis
requirement does not apply to circumstances when the provider should not render services due to
limitations arising from lack of training, experience, skill, or licensing restrictions.
6.7
franifers of Covered Persons. Without otherwise limiting AMERIGROUP s
rights pursuant to this Agreement, upon AMERIGROUP's determination made in good faith and
with reasonable belief that a Covered Person's health or safety is in jeopardy, AMERIGROUP
may require that Such Covered Person be transferred immediately for care to another provider at
AMERIGROUP's direction, and Provider shall fully cooperate with any such transfer
requirement.
6,8 _Prohibited PrkqCJces. Nothing in this Agreement shall be Construed as prohibiting
any Participating Provider from:
(a) Discussing treatment or non-treatment options with Covered Persons
irrespective of AMERIGROUPs position on such treatment or non- treatment options or whether
Such treatment options are Covered Services;
(b) Acting within the lawful scope of such provider's practice, advising or
advocating on behalf of a Covered Person for Such Covered Persons health status, medical care,
or treatment or non-treatment options, including any alternative treatments that might be self-
administered by the Covered Person;
(c) Advocating on behalf of a Covered Person within the utilization review or
grievance processes established by AMERIGROUP or individual authorization process to obtain
Medical ly'Necessary Covered Services; or
(d) Discouraging Covered Persons or those paying for their coverage from
discussing the comparative merits of different health carriers with their providers. This
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prohibition specifically includes prohibiting or limiting providers participating in those
discussions even if critical of a carrier.
6.9 Authorizations. Provider shall comply with AMERIGROUP's preauthorization
and authorization processes and procedures applicable to Provider as more fully set forth in the
Provider Manual.
6.10 Non-Discrimination –Against Particigatirr Providers. Neither AMERIGROUP
nor Provider shall discriminate with respect to participation, reimbursement, or indemnification
as to any provider who is acting within the scope of such provider's license or certification under
applicable State law, solely on the basis of such license or certification. This requirement shall
not be construed as an "any willing provider" law, and AMERIGROUP may limit provider
participation to the extent necessary to meet the needs of Covered Persons or to establish any
measures designed to maintain quality and control costs. Neither AMERIGROUP nor Provider
,shall discriminate against providers serving high-risk populations or those that specialize in
conditions requiring costly treatments.
6.11 QuItura
j Cogn _etqn,cPlan, Provider shall participate with the State's efforts to
p
promote the delivery of services in a culturally competent mariner to all Covered Persons,
including those with limited English proficiency and diverse Cultural ethnic backgrounds. To
that end, Provider agrees to comply with all AMERIGROUP policies and procedures designed to
ensure that culturally competent services are provided by AMERIGROUP both directly and
through its health care providers and subcontractors.
6.12 M—ark . Provider shall not engage in any marketing activities to Covered
Persons, for or on behalf of AMERIGROUP, except in accordance with Regulatory
Requirements, Specifically, Provider shall not distribute any marketing materials to Covered
Persons or in connection with AMERIGROUP services unless such materials are first submitted
by Provider to AMERIGROUP, and AMERIGROUP submits such materials to HCA for
approval.
6.13 C_O_T aliance with Federal_ ReLulations. AMERIGROUP and Provider
acknowledge and agree that the services provided hereunder are subject to federal regulations
governing operation of a Medicaid managed care prograrn. In connection therewith, the parties
agree to comply with all applicable requirements of 42 C.F.R. Part 434 and 42 C.F.R. Section
438.6 as they pertain to the subject matter of this Agreement.
6,1.4 I�r
_., �noy! d or Contracted Individuals. In no event shall Provider employ or
subcontract ally responsibilities hereunder to any individual who has been excluded frorn
participation Linder any federal or state health benefits program, including without limitation the
Medicaid or Medicare prograrns.
6.15 Pr 'der is
qh�ibited Referrals. In accordance with federal and state law, Provider
prohibited from referring any Covered Persons for designated health services to any entity in
which Provider, or a rnernber of Provider's immediate family, has a financial relationship,
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6 16 Coo e tion to art. Transfers of Members. Provider agrees to fully cooperate with
AMERIGROUP and with providers of other health plans in connection with any transition of
care of a Covered Person to another provider so as to assure maximum health outcomes for any
such Covered Person.
6.17
(a) In accordance with 42 CER, §422.504(i); AMERIGROUP and Provider
expressly agree in each case as permitted by law:
(i) HHS, the Comptroller General of HIIS (the "Comptroller
General") or their designees, may audit, evaluate, or inspect any books, contracts, medical
records, patient care documentation, and all other records of AMERIGROUP and Provider, as
well as their related entities, contractors, subcontractors or transferees, that pertain to any aspect
of the services performed under this Agreement, reconciliation of benefit liabilities, and
determination of amounts payable under this Agreement, or as the Secretary of HIIS (the
"Secretary") may deem necessary to enforce this Agreement.
(ii) AMERIGROUP and Provider each agree to make available, for the
purposes specified in 42 C.F.R. §422.504(d), (e), their respective premises, physical facilities
and equipment, records relating to Covered Persons and any additional relevant information that
CMS may require.
(Iii) HHS, the Comptroller General, or their designees' right to inspect,
evaluate and audit shall extend through ten (10) years from the final date of the Medicare
Program contract or the completion of a final audit by CMS related to same, whichever is later,
unless CMS determines there is a special need to retain a particular record or group of records
for a longer period and so notifies AMERIGROUP at least thirty (30) days prior to the normal
disposition date, or CMS determines there is a reasonable possibility of fraud.
(b) In accordance with 42 CER, §422,504(a)(8), Provider shall comply with
reporting requirements in 42 CER. §422.516 and the requirements in 42 C.F.R. §422.310 for
submitting data to CMS.
6.18 L
,)eIggatigli. In accordance with 42 C.F R.. §422,504(i)(3)(iii), any services or
other activity performed by a related entity, contractor, subcontractor, or first-tier or downstream
entity of Provider in accordance with a contract or written agreement shall be consistent and
comply with AMERIGROIJI"s contractual obligations with CMS, Provider shall comply with
the requirements of 42 CER. §422.504(i)(4) if any of AMERIGROUP's activities or
responsibilities under its contract with CMS are delegated to other parties. Delegated activities
shall be documented and agreed upon between AMERIGROUP and Provider.
6.19 Accouitabilijy. In accordance with 42 C.F.R. §422.504(i)(3)(ii), Provider may
only delegate activities or Functions to a provider, related entity, contractor, or subcontractor in a
manner consistent with the requirements set forth in 42 C.F,R. §422.504(i)(4).
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Name accord Ing to W`9 form with d /tr /a: Jefferson County d/b/ a Jefferson County Public Health
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6,20 Laborgor Compliance. Provider shall comply with all requirements of the
Clinical Laboratory Improvement Act ("CLIA"), regulations promulgated thereunder and any
amendments and successor statutes and regulations thereto. Upon execution of this Agreement,
Provider shall furnish written verification to AMERIGROUP that Provider's laboratory facilities,
if any, and those with which it conducts business related to Covered Persons, have appropriate
CLIA certification of registration or waiver and a CLIA identification number, Provider shall
notify AMERIGROUP in writing of any changes in Provider's CLIA certification status or the
certification status of any laboratory facilities with which Provider conducts business related to
Covered Persons within five (5) business days of any Such changes.
6,21 Ej2jh to Review Records. In addition to and without limiting any audit rights
otherwise set Forth in the Agreement and immediate access for Medicaid fraud investigators,
I Provider agrees that agents and employees of HCA shall have the right to inspect, evaluate and
audit any pertinent books, financial records, documents, papers, and records of Provider
involving financial transactions related to a Program Contract.
6,22 R_rgv id o MQniLoL_Q lity, Provider shall maintain a quality assurance system
__�_qLt . _gA__
to monitor the quality of services delivered under this Agreement and initiate corrective action
where necessary to improve quality of care, in accordance with that level of care which is
recognized as acceptable professional practice in the respective community in which the Provider
practices and/or the standards established by the Program or its designee.
6.23 Aypj�jabjjfty Qf Recur s. - s '. AMERIGROUP and Provider recognize that in the event
of termination of the Medicaid Program between AMERIGROUP and the Program t'(.,)r any of the
reasons described in the Medicaid Program Contract, AME,RIGROUP shall immediately make
available, to the Program, or its designated representative, in a usable form, any and all records,
whether medical or financial, related to AMERIGROUP's and Provider's activities undertaken
pursuant to this Agreement. The provision of such records shall be at no expense to the
Program.
6,24 (2HC—,4 If Provider is an FQIIC/IMC, AMERIGROUP shall adhere to
federal requirements for reimbursement for FQI-1C/RHC services, The agreed upon payment
from AMERIGROUP to the FQIIC/RHC is set forth in Attachment A to this Agreement. Any
bonus or incentive arrangements made to the FQI-ICs/Rl-lCs associated with Program Covered
Persons shall also be specified to the Program. AMERIGROUP shall Submit the name of
Provider and the number of Medicaid encounters paid to Provider by month of service to the
Program for reasonable cost based reconciliation purposes.
6,25 Lobt"n . By signing this Agreement, Provider certifies to the best of its
knowledge and belief that federal funds have not been used for lobbying in accordance with 45
CFR Part 93 and 31 USC 1352..). Provider shall disclose any lobbying activities using non-
federal hands in accordance with and to the extent required by 45 CFR Part 93.
6,26 CLOY Notwithstanding anything to the contrary in this
Agreement, Provider agrees to observe, protect and promote all rights of Covered Persons as
patients in accordance with all applicable laws, Program Contract and Agency requirements.
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Provider shall provide any information that a Covered person needs in order to decide among all
relevant treatment options.
6.27 survival, Upon expiration or termination of this Agreement for any reason, with
or without cause, Provider expressly agrees that Sections 9.4,6.2 and 9.5 of this Agreement shall
survive such termination or expiration.
6.28 fcanit rin Provider agrees to monitoring and periodic formal review that is
Consistent with industry standards and OIC regulations. Formal review must be completed no
less than once every three years and must identify deficiencies or areas for improvement and
provide for corrective action in accordance with 42 CFR 438.230(b).
6.29 Performance Within the U.S. Provider agrees that all services to be performed
herein shall be performed in the United States of America. Breach, or anticipated breach, of the
foregoing shall be a material breach of this Agreement and, without limitation of remedies, shall
be cause for immediate termination of this Agreement.
6.30 Americans with. I7isabilitia s .ct om liarace. Provider shall make reasonable
accommodation for Covered Persons with disabilities, in accord with the Americans with
Disabilities Act, for all services and shall assure physical and Communication barriers shall not
inhibit Covered Persons with disabilities from obtaining such services.
6.31 Lnterp te ka—ice-S. In compliance with 42 CFR 438.10(c)(4), Provider shall
assure that interpreter services are provided for Covered Persons with a primary language other
than English, free of charge. Provider shall also provide interpreter services for all interactions
between such Covered Persons and Provider including, but not limited to. all appointments,
emergency services, and all steps necessary to file grievances and appeals.
6.32 head A . i I ity, Provider shall ensure that all written information provided to
h_
Covered Persons is accurate, is not misleading, is comprehensible to its intended audience, is
designed to provide the greatest degree of understanding, and is written at the sixth grade reading
level. All such written materials must have the written approval of Anierigroup, prior to use.
6,33 Coordination of Bgenefils. Provider understands and agrees that when a Covered
Person is covered by two or more plans, the primary plan must pay or provide its benefits as if
the Program did not exist.
6,34 Pr-ca ra Provider shall comply with Anierigroup's INCA approved
Program Integrity policies and procedures and the Program Integrity requirements of the
Program Contract.
6.35 L.nrollee Selfl)eterminatitLn. Provider shall obtain informed consent prior to
treatment from Covered Persons, or persons authorized to consent on behalf of a Covered
Person, and shall comply with the provisions of the Natural Death Act (RCW 70.122) and state
and federal Medicaid rules concerning advance directives, and, when appropriate, inform
Covered Persons of their right to make anatomical gifts.
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Name according to W 9 form with d/b/a: Jefferson County d/b/a Jefferson County Plublic Healith
Federal Tax Identification Number: 91-6001322
6.36 coordination of Care. If Provider is a PCP, then Provider shall, in consultation
with other appropriate health care professionals such as care coordinators or care managers, be
responsible for the provision, coordination, and supervision of health care to meet the needs of
each Covered Person, including initiation and coordination of referrals for medically necessary
specialty care, and shall assess and develop individualized clinical treatment plans for children
with special health care needs, which ensure integration of clinical and non-clinical disciplines
and services in the overall plan of care.
637 Special_jlealth Care Needs. Provider shall identify child or adult Covered
Persons with special health care needs in the course of any contact or Covered Person initiated
health care visit and report such identification to Annerigroup.
6,38 _,StenIVzatjon and Hysterectomies. Provider shall assure that all sterilizations and
hysterectomies performed for Covered Persons are in compliance with 42 CFR 441 Subpart F,
and that the HCA Sterilization Consent Form (FICA 13-364)) or its equivalent is used.
6.39 F-_nrollce Self-Referral. Provider understands and agrees that Covered Persons
have the right to self-refer for certain services to local health departments and fancily planning
clinics, including family planning services and sexually - transmitted disease screening and
treatment services provided at family planning agencies, such as Planned Parenthood, as well as,
immunizations, sexually-transmitted disease screening and follow-up, immunodeficiency virus
(HIV) screening, tuberculosis screening and follow-Lip, and family planning services through the
local health department.
6,40 Solvency Requirements, If Provider is at financial risk, as defined in the Program
Contract, AMERIGROUP shall establish, enforce and monitor solvency requirements that
provide assurance of Provider's ability to meet its obligations.
ARTICLE VII
RECORDS
7.1 BL�cords, Provider shall ensure that infort-nation about Covered Persons, including
their medical records, shall be kept confidential in a manner consistent with state and federal
laws and regulations. Provider shall maintain medical, financial and administrative records
concerning services provided to Covered Persons in accordance with industry standards and
Regulatory Requirements, including without limitation applicable law regarding confidentiality
of Covered Pei-son information, Such records shall be retained by Provider for the period of time
required under Regulatory Requirements, but in no event less than ten (10) years from the date
the service is rendered. Provider shall provide state and federal agencies access to review records
related to services provided hereunder in accordance with Regulatory Requirements. Provider
shall permit AMERIGROUP or its designated agent to review records directly related to services
provided to Covered Persons, either by providing such records to AMERIGROUP for off-site
review, or on-site at Provider's facility, upon reasonable notice from AMERIGROUP and during
regular business hours. Provider shall obtain all necessary releases, consents and authorizations
from Covered Persons with respect to their medical records to permit AMERIGROUP access to
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such records. Provider shall supply the records described above at no charge upon request. The
rights and obligations of the parties under this section shall survive the termination of this
Agreement. Provider will have the right to audit AMERIGROUP records relating to Covered
Services rendered by Provider to Covered Person's.
7,2 Receard TransfeK. Provider shall cooperate in the transfer of Covered Persons'
medical records to other Participating Providers when required, subject to Regulatory
Requirements, and shall assume the cost associated therewith, Following a Covered Person's
request for record transfer, Provider shall transfer such Covered Person's medical records in
Provider's custody within ten (10) days following the request, or such other time period required
under applicable Regulatory Requirements.
ARTICLE VIII
COMPLAINT/DISPUTE RESOLU`TION
8,1 Co p lainvi of Covered Persons. AMERIGROLJP shall notify the Provider
_ _
concerning any complaint by a Covered Person involving that Provider or a Participating
Provider of that Provider in accordance with procedures set forth in the Provider Manual. The
provisions of this Article shall only apply to disputes that have complied fully with all grievance
and appeal procedures set forth in the Provider Manual,
82 Ne otiation.-Q-f—[N-S�s.
(a) In the event of a dispute arising out of this Agreement that is not resolved by,
or is riot within the scope of relationship management set forth in the Agreement, or that is not
resolved by informal discussions among the parties, the parties shall negotiate the dispute. Any
party may initiate negotiation by sending a written description of the dispute to the other parties
by certified or registered mail or personal delivery. The description shall explain the nature of
the dispute in detail and set forth a proposed resolution, including a specific time frame within
which the parties must act. 'File party receiving the letter must respond in writing within thirty
(30) days with a detailed explanation of its position and a response to the proposed resolution.
Within thirty (30) days of the initiating party receiving this response, principals of the party who
have authority to settle the dispute will meet to discuss the resolution of the dispute, The
initiating party shall initiate the scheduling of this negotiating session.
(b) In the event the parties are unable to resolve the dispute following the
negotiation, a party shall have the right to pursue all available remedies at law or equity,
including injunctive relief.
83 piVui _Resolution. Except as otherwise required by a specific federal or state
statute or regulation governing dispute resolution, no process for the resolution of disputes
arising out of a participating provider contract shall be considered fair under RCW 48A3,055
unless the process meets all the provisions of WAC 284-43-322,
(1) A dispute resolution process may include ail initial informal process but
illUst include a formal process for resolution of ail contract disputes.
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(2) AMERIGROUP may have different types of dispute resolution processes
as necessary for specialized concerns such as provider credentialing or as otherwise required by
law. For example, disputes over Program coverage of Covered Services are subject to the
grievance procedures established for Covered Persons.
(3) AMERIGROUP must allow not less than thirty (30) days after the action
giving rise to a dispute for providers to complain and initiate the dispute resolution process.
(4) AMERIGROUP may not require alternative dispute resolution to the
exclusion of judicial remedies; however, AMERIGROUP may require alternative dispute
resolution prior to judicial remedies.
(5) AMERIGROUP must render a decision on provider complaints within a
reasonable time for the type of dispute. In the case of billing disputes, AMERIGROUP must
render a decision within sixty (60) days of the complaint.
ARTICLE IX
TERM; TERMINATION
9,1 initial.'Ferm and Renewal. Subject to the terms and conditions otherwise set forth
in this Agreement, this Agreement shall have an initial term of two (2) years, commencing as of
the Effective Date, and shall renew automatically thereafter for successive terms of one (1) year,
unless either party notifies the other of its intent not to renew at least one hundred and twenty
(120) days prior to the end of the term.
92 'I'erqlination..�Vithout Cause, Notwithstanding any other provision included in
this Agreernent, Provider and AMERIGROUP shall each be entitled to terminate this Agreement
at any time during its term by providing one hundred and twenty (110) days prior written notice
to the other party.
9.3 -_FermirLation by E her Party for Cause. Either party may terminate this
_ --jL -------
Agreement for cause, defined as a material breach of this Agreement by the other party hereto,
upon ninety (90) days prior written notice to the other party. The notice shall set forth the
reasons for termination and provide the breaching party ninety (90) days to cure such material
breach or the termination becomes effective.
9A _1mrnediate Terminatiow Autonigic Termination.
(a) Immediate Termination. AMERIGROUP shall be entitled to terrninatc
this Agreement immediately upon AMERIGROUP's determination made in good faith and with
reasonable belief that (A) a Covered Person's health is subject to imminent danger or a
physician's ability to practice medicine is effectively impaired by an action of the Board of
Medicine or other governmental agency or (13) Provider continues a practice or pattern of (1)
substantial disregard for the rules and regulations of AMERIGYROUP with respect to patient care,
or (2) material deviation from the practice and quality assurance standards adopted by
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AMERIGROUP, or (C) Provider's continued participation could adversely affect tile care of
Covered Persons. in addition, AMERIGROUP may immediately terminate this Agreement upon
the filing of a petition in bankruptcy for liquidation or reorganization by or against Provider, if
Provider becomes insolvent, or if a receiver is appointed for Provider or its property. In the case
of termination under this subsection, the effective date of such termination shall be the date set
forth in AMERIGROUP's written notice to Provider notifying Provider of such termination,
(b) AutoTatic Termination. This Agreement shall automatically and
immediately terminate upon the expiration, surrender, revocation, restriction or suspension of
any professional license required for Provider to perform the services contemplated hereunder or
Provider's participation in any applicable Program. In addition, if Provider is terminated, barred,
suspended or otherwise excluded from participation in, or has voluntarily withdrawn as the result
of a settlement agreement related to, any program under Titles XVIII, XIX or XX of the Social
Security Act, this Agreement shall automatically and immediately terminate.
(c) Apng2jl of Term i nation . In the event that Provider objects to termination
of the Agreement for any reason, Provider shall utilize AMERIGROUP's ComplaintlDispute
Resolution process as more fully set forth in Article VIII of this Agreement.
9.5 Continuation Of Care,
(a) In the event of the termination of this Agreement for any reason except
termination of this Agreement for cause by AMERIGROUP pursuant tca subsection (c) below,
any Covered Person who is suffering from and receiving active health care services for a chronic
or terminal illness or who is an inpatient shall have the right to continue to receive health care
services from Provider for a period of up to sixty (60,) days from the date of the termination of
this Agreement or until the Covered Person's discharge from inpatient facilities up to ninety (90)
days, whichever time is greater, Any Covered Person who is pregnant and receiving treatment in
connection with that pregnancy at tile time of termination of this Agreement may continue to
receive health care services from Provider for the remainder of her pregnancy and six (6) weeks
post-partum.
(b) During the continuity of care provision described in subsection (a) above,
Provider shall continue to provide services in accordance with the terms of this Agreement
applicable immediately prior to the termination of this Agreement, and AMERIGROUP shall
continue to meet all of the obligations of this Agreement.
(c) A Covered Person shall not have the right to continuation of care ill' the
terl-nination of this Agreement is for loss of Provider license, or if the termination of this
Agreement is due to reasons related to quality of health care services rendered, health, safety or
welfare of Covered Persons.
ARTICLE X
MISCELLANEOUS
10,1 Amendment.
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(a) This Agreement may be amended by the mutual agreement of the parties
as evidenced in a writing, signed by the parties.
(b) In addition, AMERIGROUP shall be entitled to amend this Agreement as
follows without the written agreement of Provider:
(i) Upon thirty (30) days prior written notice to Provider, if the
amendment is being effected by AMERIGROUP to comply with a Regulatory Requirement,
such amendment shall be effective as of the effective date set forth in the amendment.
Notwithstanding the above, AMERIGROUP shall be entitled to amend the Agreement upon less
than thirty (30) days prior written notice if a shorter notice period is required in order to comply
with such Regulatory Requirement,
(6) Upon sixty (60) days prior written notice to Provider, to the extent
the amendment is being effected by AMERIGROUP for a purpose other than compliance with a
Regulatory Requirement. Provider shall be entitled to object to the amendment, by written
notice provided to AMERI(.JROUP within sixty (60) days following Provider's receipt of such
amendment, if a timely objection is received by AMERIGROUP, the the amendment shall take
effect until the parties mutually agree on a resolution to the objection or this Agreement is
terminated in accordance with the terms hereof,
(iii) An amendment to the Agreement may not be made retroactive
without the consent of the Provider.
10.2 _Non-Exclus
. ivj!y� Volume, This Agreement shall not, nor shall it be construed to,
limit or restrict AMERIGROUP in any manner from entering into any other agreements of any
nature whatsoever with other persons or entities for the provision of the same or similar services
contemplated hereunder. Neither this Agreement, nor anything contained herein, shall guarantee
or obligate AMERIGRO(.JP or any other party to provide any minimum number of` referrals to
Provider hereunder.
10.3 As--,,ignmqnt.
(a) This Agreement may not be assigned by Provider without the prior written
consent of AMERIGROUP and may riot be assigned by either party without the consent of HCA.
(b) In the event of a partial assignment of this Agreement by AMERIGROUP,
the, obligations of the Provider shall be performed for AMERIGROLJP with respect to the part
retained and shall be performed for AMERIGROUP assignee with respect to the part assigned,
and such assignee shall be solely responsible to perforin all obligations of AMERIGROUP with
respect to the pail assigned.
(c) The rights and obligations of the parties hereunder shall inure to the
benefit of, and shall be binding upon, any perinitted successors and assigns of the parties hereto.
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Name accordMg to W-9 form with d/b/a: Jefferson County d/b/a Jefferson County Pubic Health
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10.4 -Indemnification.
(a) Provider agrees to indemnify, defend, and hold harmless AMERIGROUP
and its officers, employees and agents from and against any and all liability, loss, claim, damage
or expense, including defense costs and legal fees, incurred in connection with (i) Provider's
breach of any representation and warranty made by Provider in this Agreement, and (ii) claims
for damages of any nature whatsoever, including, but not limited to, bodily injury, death,
personal injury or property damage arising from Provider's delivery of health care services or
Provider's performance or failure to perform Provider's obligations hereunder.
(b) AMERIGROUP agrees to indemnify, defend, and hold harmless Provider
and, if Provider is an entity, its officers, employees and agents from and against any and all
liability, loss, claim, damage or expense, including defense costs and legal fees, incurred in
connection with (i) AMERIGROUP's breach of any representation and warranty made by
AMERIGROUP in this Agreement, and (ii) claims for damages of any nature whatsoever,
arising from AMERIGROUP's performance or failure to perform its obligations hereunder.
(e) Notwithstanding the foregoing subsections (a) and (b), this Section shall
be null and void to the extent that it is interpreted to reduce insurance coverage to which either
party is otherwise entitled, by way of any exclusion for contractually assumed liability or
otherwise.
(d) Provider agrees to indemnify and hold harmless HA and its employees
against all injuries, deaths, losses, damages, claims, suits, liabilities, judgments, costs and
expenses which may in any manner accrue against FICA or its employees through the intentional
misconduct, negligence, or omission of the Provider, its agents, officers, employees or
contractors.
IM MLa�lver. Either party's waiver of any breach or violation of this Agreement by tile
other party shall not, nor shall it be construed to, constitute a waiver of any Subsequent breach or
violation of this Agreement by the other party.
10.6 Sg�yerqjb L lity. "The invalidity or uncriforceability of any provision contained herein
shall not affect the validity of any other provisions of this Agreement, and this Agreement shall
be construed in all respects as if such invalid or unenforceable provision were or pitted, or, to the
extent permitted by applicable law, such invalid or unenforceable paragraph shall be replaced
with another paragraph as similar in terms as may be possible and as may be legal, valid and
enforceable.
103 Construqf This Agreement shall be construed without regard to ally
�ion.
presumption or other rule requiring construction against the party causing this Agreernent to be
drafted.
10.8 LQtice. Any notice required to be given under this Agreement shall be sent by
certified mail, return receipt requested, postage prepaid; hand delivery; overnight prepaid
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Name according to W-9 form with d/b/x jeffersoin County d/b/a JefferSWI COUnty Public Health
Federal Tax Identification Number: 91-6001322
delivery; or confirmed facsimile to the addresses set forth below, or to such other address
designated by a party hereto by notice to the other party pursuant to the terms of this Agreement:
If to AMERIGROUP, at the address set forth in the Provider Manual.
If tea Provider, to the address set forth in Provider's AMERIGROUP participation
application.
tl,4�� eildent Contractor '!atus. Nothing contained herein shall, or shall be
construed to, create a partnership, joint venture or any other relationship between the parties
hereto other than that of independent contractors.
10.10 Entire A&�f. This Agreement, and any exhibits, attachments and
arnendillents hereto,, constitute the entire Agreement and understanding between the pat-ties with
respect to the subject matter hereof,,, and supersede any prior understandings and agreements
between the parties, whether written or oral, with respect to the subject matter hereof.
10.11 Captions. The section headings in this Agreement are for convenience of
reference only, shall not define or limit the provisions hereof, and shall have no legal effect
whatsoever,
10,12 Coordination of Defense of Claims. The parties hereto shall make all reasonable
efforts, consistent with advice of counsel and their requirements of their respective insurance
policies and carriers, to coordinate the defense of claims in which either party is named a
defendant, or has a substantial possibility of being named a defendant.
10,13 CLjoverning Law, This Agreement shall be governed by and construed in
accordance with the laws of the State of Washington, excluding and without application of any
conflicts of law principles.
10.14, {room eT.q[ts. '['his Agreement and any amendment hereto may be executed in
two or more counterparts, each of which shall be deemed to be an original and all of which taken
together shall constitute one and the same agreement.
10,15 NKtLi-lLetfoMance, Neither party shall be liable, nor deemed to be in default
hereunder, for any delay in performance or failure to perform under this Agreement which
results directly or indirectly from acts of God, civil or military authority, acts of public enemy,
war, accidents, fires, explosions, employee strikes or other work interruptions, earthquakes,
floods, failure of transportation, or any cause beyond the reasonable control of such party.
Provider acknowledges and agrees that this Agreement and the arrangement contemplated herein
is subject to regulation by state and federal governmental authorities. In the event that any action
of any such governmental authority impairs, limits, or delays either party's performance of" any
obligation hereunder, that party shall be excused from Such performance, and party's failure to
perform such obligation for such reason shall not constitute a breach of this Agreement.
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Name according to W-9, form with d/b/'a: Jefferson County d/b/a Jefferson County Public Health
Federal Tax Identification Number: 9160➢1322
IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed
by their duly authorized officers or agents.
AMERIGROUP:
AMERIGROUP Washington, Inc.
No
ante]
. . ...............
Provider:
Jefferson County d/b/a Jefferson County Public
Health
By:
(authorized signature)
acne]
ifle]
Address]
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Name ac(,ording to W-9 form with d/b/a: Jefferson County d/b/a Jefferson Coon typublic Health
Federal Tax ldentificatlon NUMber: 91-6001322
ATTACHMENT A
AMERIGR10UP Washington, Inc.
Federal Qualified Health Clinic ("FQHC")
Medicaid Reimbursement
AMERIGROUP shall compensate Provider for Covered Services provided to Covered Persons,
subject to all terms and conditions of this Agreement, benefit design, coordination of benefits
(COB), applicable authorization requirements, applicable coinsurance, program eligibility and
the Provider Manual, in an amount equal to the lesser of Eligible Charges or the amounts shown
below.
Section 1: Fee Reimbursement
Service Description Billing Code Rate Method
Applicable 100 % of the Washington
,Professional Services CPTAICPCS Codes State Medicaid Fee Per Service
I Schedule
Payments specified as "Washington State Medicaid Fee Schedule" refer to the applicable
Washington State Medicaid Fee Schedule in effect as of the date of service for the
market(s) and prograrn(s) covered by the Agreement at the time the Covered Service is
initiated to the Covered Persons. AMERI►ROUP will update the Fee Schedule no more
than sixty (60) days from the date of receipt of notice of final changes or on the effective
date of such changes, whichever is later. Fee Schedule changes will be applied on a
prospective basis. AM[`R.K.;R.0UP will not be responsible for interest payments that are
the result of late notification to AMERICYROUP of Fee Schedule changes.
2. Provider must bill using the appropriate i-nodifiers for services rendered, if applicable.
Section 11: Notes
All services billed by Provider will be submitted on a CMS 1500 (or its successor) form
or corresponding electronic format.
2, Eligible Charges are those charges billed by the Provider subject to conditions and
requirements which make the service eligible for reimbursement. Eligibility for
reimbursement of the service is deperident upon application of the following conditions
and requirements: member program eligibility, provider program eligibility, benefit
coverage, authorization requirements, Provider Manual guidelines, AMERIGROUP
administrative, clinical, and reimbursement policies, and code editing logic. The allowed
amount reimbursed for the eligible charge is based on the applicable fee schedule or
WA Federal Qualified Health Clinic-P I 1 -
Name according to W-9 form with d/b/a: Jefferson County d/b/a Jefferson County Public Heakh
Federal Tax identification Number: 91-6001322
contracted/negotiated rate after application of coinsurance, co-payments, deductibles, and
coordination of benefits. AMERIGROUP will not reimburse Providers for items the
Provider receives free of charge and items the Provider provides to the mernber free of
charge.
Section III: Exclusions
DMEPOS, PEN, 1-lome Health, and 11orne Infusion services are not reimbursable under
this Agreement, Provider must contract with Amerigroup's LAME, Home Health and
I lorne Infusion vendor directly.
2, Any services not specified in the Fee Schedule(s) or Attachment are not reimbursable.
WA FederM Qualihod Heald, Unic P .2 -