Provider Agreement for Participation in Pennsylvania s Consolidated and Person/Family Directed Support (P/FDS) Waivers Deleted: Medical Assistance Program This agreement, made this day of, 20, between the Commonwealth of Pennsylvania, Department of Public Welfare, herein referred to as the Department and the Provider (Provider Name) (Provider Master or National Provider Index Number), (Provider Federal Employer Identification Number), herein referred to as the Provider related to the provision of services covered by Pennsylvania s Office of Developmental Programs Consolidated and P/FDS Medicaid Waivers 1. This agreement will remain in effect until superseded by an updated Department Provider Agreement, or until terminated by either the Department or the Provider. THE PROVIDER AGREES: A. To comply with all of the requirements of the Department s Consolidated and P/FDS Medicaid Waivers as well as any other applicable ODP regulations and ODP bulletins issued by the Department, and any applicable service-specific addendums to this agreement. The Provider acknowledges his or her responsibility to become familiar with those requirements since they may differ significantly from those of other thirdparty payer programs. B. To meet provider qualification standards, as outlined in Appendix C of the Consolidated and P/FDS Waivers, for services the Provider is rendering. If the provider intends to render services for which they are not currently qualified, the Provider must be qualified prior to the delivery of the new services. 1. To immediately notify the Department of any change that impacts or has the potential to impact the Provider s qualification status. C. To maintain adequate records that fully describe the nature and extent of all goods and services provided for a minimum of four years or until the completion of any audit. The Provider agrees to provide records to the United States Department of Health and Human Services, Pennsylvania s Medicaid fraud control unit, and the Department, and/or its designee upon 1 This includes Waiver-related services not eligible for federal financial participation. Deleted: is entered into by Deleted: _ Deleted: Inserted: Deleted: M/NPI FEIN Inserted: M/NPI FEIN Deleted: to provide Inserted: Deleted: (Person/Family Directed Support) Deleted: This agreement applies to the following waivers (check all that apply): Pennsylvania s Consolidated Waiver, CMS Control # 0147.90 Pennsylvania s Person/Family Directed Support (P/FDS) Waiver, CMS Control # 0354.90 Deleted: PA Office of Deleted: Person Family Directed Support ( Deleted: ) Deleted: OMR Deleted: OMR Deleted: s Deleted: of Public Welfare Deleted: them
request and at no charge. This requirement does not prescribe record requirements by other laws, regulations, or agreements. 1. Records must be made immediately available upon request during onsite visits by the United States Department of Health and Human Services (DHSS), the Medicaid fraud control unit (MFCU), the Pennsylvania Department of Public Welfare, Office of Developmental Programs and/or its designee. 2. Copies of records must be forwarded to the United States Department of Health and Human Services (DHSS), the Medicaid fraud control unit (MFCU), the Department and/or its designee, upon written request. Copies of records must be provided within 10 calendar days of the request. D. To protect the confidentiality of all participant information, including names, addresses, waiver services provided and medical data about the participant, such as diagnoses and past history of disease and disability. Such information may only be released to a third party upon the consent of the waiver participant, except when the information is released to other service providers or as otherwise permitted by State law, Federal law, regulation, or other legal process. E. To provide service on a non-discriminatory basis. The Provider will not discriminate on the basis of race, color, religious creed, ancestry, union membership, age, gender, sexual orientation, gender identity or expression, national origin, AIDS or HIV status, or disability. The Provider will act in compliance with the Americans with Disabilities Act. F. To not knowingly employ or contract with a person, partnership or corporation which has been disqualified from providing or supplying services to Medical Assistance participants unless the Provider receives prior written approval from the Department and/or its designee. G. To accept payments made by the Department as payment in full for Waiver services and services related to the Waiver but ineligible for federal financial participation. Payments for Waiver services are based on rates that are established through the following ways: 1. Cost Report: For services for which rates are established through the completion of the cost report, in accordance with instructions issued by the Department, the Provider agrees to: i. Complete the cost report using the instructions provided by the Department. ii. Submit the completed cost report as per timelines established by the Department. Deleted: Original r Deleted: recipie Deleted: of the Pennsylvania Department of Public Welfare, Office of Deleted: Developmental Programs waiver program or its designee Inserted: Developmental Programs Deleted: sex Deleted: or or its designee s Deleted: Waiver payments Deleted: the Deleted: rendered Formatted: Indent: Left: 99 pt
iii. Provide all necessary information to support the calculation of their revenue target as per the Department s Revenue Reconciliation policy. The Provider agrees to reach agreement concerning the target in a timely fashion. iv. Cooperate with the recoupment of payments in excess of their revenue target. The provider acknowledges that when they have received payments in excess of their revenue target that the Department will recoup the excess funds. v. Pay back any overpayments within 45 calendar days of the final revenue reconciliation. If the Provider does not repay the funds, the Department may withhold payments until all overpayments are repaid. vi. Comply with Department desk review and audit requirements related to the cost report. 2. Fee Schedule: For services with rates published on a Departmental fee schedule, the Provider agrees to accept the published rate as payment in full. 3. Public Rate: For services for which rates are established for the general public and not reimbursed through a cost report or fee schedule methodology, the Provider agrees to: i. Not charge Waiver participants more than the rate that is charged to the general public; ii. Submit the public rate for the following State fiscal year to the Department by January 31 st of each year. iii. Submit any rate changes to the Department 30 calendar days prior to their effective date. 4. Transportation: For transportation services, the Provider agrees: i. For Transportation (Mile), to use the current State rate for mileage reimbursement effective the January 1 st immediately preceding the beginning of the impacted fiscal year. ii. For Public Transportation, see paragraph F-c. iii. For Transportation (Trip) and Transportation (Per Diem), to cooperate with the Administrative Entity in establishing the service rate as per Departmental instructions. H. That rates or fees per unit of service may be published as a Departmental bulletin by the Department for selected services. These published fees represent the maximum amount in which the Department or its designee will participate for the identified services. When payment is based on established fees, the provider is not required to negotiate or determine unit costs. Formatted: Font color: Auto Formatted: Indent: Left: 54 pt Formatted: Indent: Left: 54 pt Formatted: Indent: Left: 99 pt Formatted: Indent: Left: 54 pt Formatted: Indent: Left: 99 pt Deleted: <#>That payments for waiver eligible services will be in accordance with the 55 Pa. Code Chapter 4300 County Mental Health and Mental Retardation Fiscal Manual and Title 42, CFR Part 447, Payments for Service. <#>That payment for non-eligible services must be covered in the standard county/non-county administrative entity provider contract. Deleted: are considered to be reasonable cost for the services covered by the fee schedule. They
I. Not to seek any additional payment from the participant. If the Department and/or its designee denies payment or requests repayment because an otherwise covered service was not authorized or was not preauthorized (if required), the Provider agrees not to seek payment from the participant for that service. J. To seek payment from a participant s other insurances and programs 2 before submitting claims to the Department or its designee. If payment is made by both the Department and a participant s insurance or other program, the Provider shall refund the Department within 45 calendar days of receipt, the amount paid by the Department. K. That claims for Waiver and Waiver related services under this agreement may only be made on or after the effective date of this agreement. L. To ensure that all claims submitted are completed in accordance with guidance issued by ODP or its designee. The Provider accepts responsibility for the accuracy of all claims submitted under his or her provider number to the Department and/or its designee. This includes claims submitted by the Provider and claims submitted on his or her behalf. M. That all claims submitted under the Master or National Provider Index number shall be for authorized Waiver or Waiver-related services ineligible for federal financial participation that were actually provided to individuals as documented in their approved individual support plan and as described in the claim. The provider cannot bill or receive payment for services that are not authorized in the individual support plan, or for services without the supporting documentation required by Bulletin 00-07-01, Provider Billing Documentation Requirements for Waiver Services, or any approved revisions. This includes attendance records or other documentation to substantiate claims for medical and therapeutic leave for Residential services. N. To use appropriate codes and modifiers when submitting claims for Waiver and Waiver related services. O. That factoring arrangements are prohibited. A factor means an individual or service provider or organization, such as a collection agency or service bureau, that advances money to a provider for accounts receivable that the provider has assigned, sold or transferred to the individual organization for an added fee or a deduction of a portion of the accounts receivable. A factor does not include a business agent, such as a billing 2 This includes room and board costs collected from the participant as per 55 Pa. Code Chapter 6200. Deleted: <#>The Department or its designee will participate in the cost of reimbursement to unit of service providers. <#>That allowable cost standards shall be used by the Department or its designee for determining rates for unit of service contracts The Department or its designee will not participate in the portion of a rate which contains disallowed costs or exceeds... [1] Deleted: recipie Deleted: and/or its designee Deleted: other Deleted: Developmental Programs... [2] Inserted: Developmental Programs Deleted: and/or its designee Deleted: his or her Deleted: provider Deleted: w Deleted: written Deleted: therapeutic and medical... [3] Inserted: therapeutic and medical... [4]
service or an accounting firm that furnishes statements and receives payments in the name of the provider, if the agency s compensation for this service is: 1. Related to the cost of processing the billing; 2. Not related on a percentage or other basis to the amount that is billed or collected; and 3. Not dependent on the collection of the payment. P. To acknowledge that the submission of false or fraudulent claims could result in criminal prosecution and civil and administrative sanctions, including exclusion from participation in Medicare, Medicaid and all other Federal health care programs. 1. In the event the Provider is excluded or temporarily suspended from participation in Medicaid, the Provider agrees to immediately cease the submission of claims and notify the Department. Q. To furnish the Department and/or its designee within 35 calendar days of a request from the Department and/or its designee, full and complete information about: 1. The ownership of any subcontractor with whom the Provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request. 2. Any significant business transaction between the Provider and any wholly-owned supplier, or between the Provider and any subcontractor during the 5-year period ending on the date of the request; and 3. Any ownership interest exceeding 5 percent held by the Provider in any other Medical Assistance Provider. R. That before the Department enters into or renews a provider agreement, the Provider agrees to disclose to the Department and/or its designee the identity of any person who: 1. Has an ownership or controlling interest in the Provider, or is an agent or managing employee of the Provider; 2. Has been convicted of a criminal offense related to that person s involvement in the Medicaid or Medicare programs; and 3. Any ownership interest exceeding 5 percent held by the Provider in any other Medical Assistance Provider. S. To utilize the Home and Community Services Information System (HCSIS) for enrollment/sign-up, Incident Reporting and Management, and Provider Qualification; and maintain current provider information in HCSIS. Failure Deleted: he Provider Deleted: s Deleted:. This may Deleted: e Formatted: Indent: Left: 54 pt Deleted: s request Deleted: Deleted: Providers must
to maintain current information will result in the denial of claims for services and service locations with incorrect information. T. To submit applications for PROMISe enrollment as necessary, maintain current provider information in PROMISe, submit claims through PROMISe for Waiver services and Waiver-related services not eligible for federal financial participation. U. To comply with all federal audit requirements, including: the Single Audit Act, as amended; the revised Office of Management and Budget (OMB) Circular A-133, Audits of States, Local Government, and Non-Profit Organizations; Title 45, CFR 74.26, and any other applicable law or regulation that may be enacted or promulgated by the federal government. V. If the Provider is rendering services licensed under 55 Pa. Code Chapters 3800, 5310, and/or 6400, to adhere to the policies and procedures established by the Department governing Waiver capacity management, including the Department approved program capacity and management of vacancies. 1. Approved program capacity refers to the capacity, or number of individuals to be supported, that has been approved by the Department for each setting licensed under 55 Pa. Code Chapters 3800, 5310, or 6400. 2. Vacancy management refers to the process of identifying and filling permanent vacancies in settings licensed under 55 Pa. Code Chapter 3810, 5310, and 6400. Vacancy management includes adhering to the Department approved program capacity, notifying the appropriate Office of Developmental Programs Regional Office when a vacancy is anticipated or created, and cooperating with filling the vacancy as per Departmental policies and procedures. W. That qualified providers of service may refuse to offer services for due cause, specifically conflict of interest, conflict with the Provider s service admission policy, and a determination by the Provider that the service needs of the person are beyond the Provider s qualifications to address in accordance with state and federal requirements. X. That the Administrative Entity is authorized to deny the choice of a qualified Provider when: 1. The Provider does not sign or comply with this agreement; 2. The Provider has failed to comply with provider qualification standards as determined by the Department; 3. The Provider has failed to deliver services in accordance with the individual s support plan; Deleted: and must Deleted: bill Deleted: in accordance with the Department s approved schedule Deleted: <#>In arranging for waiver funded services, the Administrative Entity may not limit access to willing, qualified providers in any way that would violate freedom of choice under the Service Preference Bulletin 00-00-09 or any approved revisions made by the Department. Q Deleted: <#>ualified Deleted: <#>providers of service who meet provider qualification in the Department s approved waiver application may not be denied access to providing services on the basis of single source contracting or other practices which would deny or limit choice of qualified providers to the participant Inserted: <#>participant Deleted: <#>individual Deleted: <#> or his/her legal Deleted: <#>representativ Inserted: <#>surrogat Deleted: <#>surrogate. Inserted: <#> That qualified providers of service may refuse to offer services for due cause, specifically conflict of interest, conflict with the Provider s service admission policy, and a determination by the Provider that the service needs of the person are beyond the Provider s qualifications to address in accordance with state and federal requirements. Deleted: Although a denial of a qualified provider is subject to Provider Dispute Resolution review, t Deleted: or the AE/Provider contract required in accordance with the County MH/MR Fiscal Manual, 55 Pa. Code Chapter 4300 and provisions of the Administrative Entity s operating agreement with the Department Deleted: <#>The provider s rate or schedule of charges for service is... [5]
4. The Provider has furnished services of a quality that does not meet professionally recognized standards of health care, as defined in 42 CFR 1001.2. 5. The Department has placed restrictions on the Provider for performance issues. 6. The Provider has been excluded or temporarily suspended from participation in Medicaid. Y. To participate in external reviews by the Department or its designee and to develop and implement timely corrective action plans in response to monitoring findings. This includes monitoring conducting by Administrative Entities, as per the Administrative Entity Operating Agreement, and other external reviews, such as Independent Monitoring for Quality, and technical assistance and recommendations provided by a Health Care Quality Unit, Positive Practices Resource Team, or other training and technical assistance entities designated by the Department. The Provider agrees to cooperate with the Department and/or its designee regarding the implementation of Department-directed or approved corrective action plans. Z. To adhere to Departmental regulations, waiver requirements, and policy and procedure bulletins. The Provider is responsible to maintain sufficient staff to comply with waiver requirements and to meet the provisions of this agreement to render services authorized in participant individual support plans. This includes the development and implementation of backup plans as per the Consolidated and P/FDS Waivers and applicable regulatory requirements. AA. To not utilize prone position manual restraints. BB. To develop an organizational capacity to access, review and analyze data for quality improvement purposes, collaborate with system partners in improving local services and supports, and share quality information with partners and stakeholders. CC. That the provider has appeal rights under 55 Pa. Code Chapter 41. DD. That the provider may terminate their enrollment for a service or service location without cause at least thirty (30) calendar days prior written notice to the Department and the appropriate Administrative Entity. This includes the termination of a service to a particular participant. EE. That the Department may terminate the Provider s enrollment for a service or service location with at least thirty (30) calendar days written notice to the Provider. The Department reserves the right to terminate the Deleted: s Deleted: enrollment Deleted: be Deleted: d Deleted: by the provider Deleted: upon Deleted: and the Department of Public Welfare
Provider s enrollment without notice in situations where the health and welfare of Waiver participants is in jeopardy. FF.When the Provider s service or service location is terminated, to continue to provide services upon termination and be paid for such services until the transition of participants to new providers occurs. This includes cooperation with planning transition activities, and sharing applicable records. Deleted: <#>That the provider s enrollment, when approved by the Department of Public Welfare, is effective on and will continue until notified that its enrollment is terminated. Deleted: T Provider Signature Date Name of Provider Representative 3 (Typed or Printed) Provider Name of Business (Typed or Printed) Provider Address (Typed or Printed) Provider Telephone Number (Typed or Printed) Provider Email Address (Typed or Printed) 3 The Provider representative attests that they function in a capacity that permits them to bind the Provider to the conditions and requirements contained in this agreement.
Page 4: [1] Deleted Kelly Svalbonas 10/3/2008 3:28 PM The Department or its designee will participate in the cost of reimbursement to unit of service providers. That allowable cost standards shall be used by the Department or its designee for determining rates for unit of service contracts The Department or its designee will not participate in the portion of a rate which contains disallowed costs or exceeds maximum levels of reimbursement established by the Department. Page 4: [2] Deleted ksvalbonas 10/20/2008 2:16 PM Developmental Programs and/or its designee Page 4: [3] Deleted ksvalbonas 11/11/2008 12:37 PM therapeutic and medical leave Page 4: [4] Inserted Kelly Svalbonas 10/3/2008 3:33 PM therapeutic and medical leave. Page 6: [5] Deleted Kelly Svalbonas 10/3/2008 3:39 PM The provider s rate or schedule of charges for service is higher than necessary and reasonable for the service, as determined by the Administrative Entity; or