HomeMy WebLinkAboutWA ST DOC - Ambulance Trasports of Coyote Ridge Inmates PROVIDER AGREEMENT
Department of Corrections
The Department of Corrections(DOC)administers a health services program that provides medically
necessary health care to individuals in its custody(DOC Indlvlduals). DOC will pay for covered healthcare
services, equipment and supplies provided to DOC Individuals by a DOC Partic/pat/ng Provider.
To be considered a DOC Particfpatfng Provider, a provider must be enrolled as a Washington Medicaid
Provider and have a signed DOC Provider Agreement.As a DOC Participating Prov►der in the individual
health services program,you agree to the following:
1. Contract Term.The Contract Term shall continue until terminated by either party with 30 days' notice.
2. Governing Law and Venue.This Agreement shall be governed by the laws of the State of Washington.
In the event of a lawsuit involving this Agreement,venue shall be proper only in Thurston County,
Washington.
The DOC ParticPpating Provlder is subject to and shall comply with all federal and state laws, rules, and
regulations in effect at the time the service is rendered, which are incorporated into this Agreement by this
reference.
3. License.The DOC Partic/pat/ng Provider shall be licensed, certified, or registered as required by State
and/or Federal law. The DOC Particlpat/ng Prov/der will notify DOC within seven (7)days of learning of any
adverse action initiated against the license, certification, or registration of the DOC Particlpating Provider or
any of its officers, agents or employees. Providers are required to submit copies of current licensure upon
renewal.
4. Billing and Payment.The DOC Particlpat/ng Provider agrees:
a. Billing and reimbursement will be through Washington State Health Care Authority's(HCA) ProviderOne
payment system for dates of service September 1, 2012 and thereafter.
b. DOC Participating Provlders of hospital services(inpatient or outpatient) must bill and be paid through the
HCA ProviderOne system under the rates and methodologies in use by the state Medicaid program, as
required by Laws of 2012, Chapter 237. Claims for services provided by DOC Particlpatfng Providers outside
of a hospital setting must be submitted electronically through ProviderOne but will be paid using DOC rates
and reimbursement methodologies. DOC fee schedules and reimbursement methodologies are found at the
following website: htt s://www.doc.wa. ov/corrections/services/health- roviders/claims-billin .htm.
NOTE: If the signed contract is not returned within 30 days of receipt, the claims will be processed at the
Medicaid rate.
c. The procedure codes and fee schedule amounts in the documents listed on the website page do not
necessarily indicate coverage or payment.All coverage and payments are subject to preauthorization
requirements. The detailed billing and coverage information are found using the following link:
htt ://www.doc.wa. ov/corrections/services/health- roviders/default.htm.
d. To accept as sole and complete remuneration the amount paid in accordance with the reimbursement
rate for services covered under this Provider Agreement, except where payment by the DOC Individual is
authorized by DOC. In no event shall DOC be responsible, either directly or indirectly, to any subcontractor
or any other party that may provide services for an Individual's elective service.
e. To be held to all the terms of this Agreement even though a third party may be involved in billing claims
to DOC. It is a breach of this Agreement to discount client accounts(factor)to a third-party biller or to pay a
third party biller a percentage of the amount collected.
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5. Disclosure.The DOC Particfpating Provlder agrees to submit full and complete disclosure on the
enrollment application the following:
a. Ownership and control information;
b. Identity of any person who has ownership or control interests in the DOC Partfcipating Provlder, or is an
agent or managing employee of the DOC Part►clpating Provider,who has been convicted of any felony
and/or under the supervision of DOC; and
c.Any denial, termination, or lack of professional liability coverage, or any change in professional liability
coverage, including restrictions, modifications, or discontinuing coverage.
6. Material/Substantial Changes.At any time during the course of this Agreement,the DOC Part/c/pat/ng
Provlder agrees to notify DOC of any material and/or substantial changes in information contained on the
enrollment application given to DOC by the DOC Part/cipat/ng Provider. This notification must be made in
writing within thirty(30) days of the event triggering the reporting obligation.A change in ownership cancels
this agreement and a new agreement and provider number must be requested. Material and/or substantial
changes include, but are not limited to changes in:
a. Ownership;
b. Licensure;
c. Federal tax identification number;
d.Additions, deletions, or replacements in group membership; and
e.Any change in address or telephone number.
7. Inspection; Maintenance of Records. For six(6)years from the date of services, or longer if required
specifically by law, the DOC Partic/patPng Provider shall:
a. Keep complete and accurate medical and fiscal records that fully justify and disclose the extent of the
services or items furnished and claims submitted to DOC.
b.The DOC Participating Provider shall make available upon request appropriate documentation, including
client records, supporting material, and any information regarding payments claimed by the DOC
Participating Provlder, for review by the professional staff within DOC, the Washington State Health Care
Authority or the Secretary of the U.S. Department of Health and Human Services. The DOC Participating
Provider understands that failure to submit or failure to retain adequate documentation for services billed to
DOC may result in recovery of payments for medical services not adequately documented and may result in
the termination or suspension of the DOC Participating Provlder from participation in the DOC Individual
health program and other state medical assistance and medical care programs.
8.Audit or Investigation.Audits or investigation may be conducted selectively and/or randomly to audit
the accuracy of fees and the medical billings submitted to DOC. DOC, or its agent, may review the
Individual's health care record to assure that the Individual received the services for which the bill was
submitted. Whenever an audit establishes that the services rendered were not authorized or medically
necessary, DOC shall not pay the cost for such services nor shall the Individual be held accountable for
such costs.
The DOC Participating Provfder is liable for any excess payment received and must repay the excess
payment plus accrued interest on the excess payment at the rate of one percent per month for each month
for the period from the date which the payment was made to the date upon which payment is made to DOC.
If an audit or investigation is initiated, the DOC ParticipatPng Provider shall retain all original records and
supportive materials until the audit is completed and all issues are resolved even if the period of retention
extends beyond the required 6 year period.
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9. Confidentiality.The DOC Participating Provider may use Personal Information and other information
gained by reason of this Agreement only for the purpose of this Agreement. The DOC Participating Provider
shall not disclose, transfer, or sell any such information to any party, except as provided by law.
10. Equality in Compensation.The DOC Participating Provlder must ensure that similarly employed
individuals in its workforce are compensated as equals, consistent with the following:
Employees are similarly employed if the individuals work for the same employer, the performance of the job
requires comparable skill, effort,and responsibility, and the jobs are performed under similar working
conditions. Job titles alone are not determinative of whether employees are similarly employed.
DOC Part/c/pating Provider may allow differentials in compensation for its workers based in good faith on
any of the following:
I. A seniority system; a merit system; a system that measures earnings by quantity or quality of
production; a bona fide job-related factor or factors; or a bona fide regional difference in
compensation levels.
II. A bona fide job-related factor or factors may include, but not be limited to, education, training, or
experience,that is: consistent with business necessity; not based on or derived from a gender-
based differential; and accounts for the entire differential.
III. A bona fide regional difference in compensation level must be: consistent with business necessity;
not based on or derived from a gender-based differential; and account for the entire differential.
This Contract may be terminated if the DOC or the Department of Enterprise Services determines that the
DOC Participating Provfder is not in compliance with this provision.
11. Medical General Terms and Conditions for DOC Participating Providers. The DOC Part/cfpating
Provlder shall provide services to eligible Individuals consistent with the terms of the Offender Health Plan
and the Medical General Terms and Conditions for DOC Participating Providers(MGT&C), which are both
incorporated by reference. The OHP and the MGT&C are available upon request to
docmedicalcontracts�doc1.wa.qov Questions regarding the terms of the Offender Health Plan or
Individual eligibility should be directed to the DOC Health Services Contract Manager at
docmedicalcontracts doc1.wa. ov
12. Contract Representatives.
DOC's contract manager for this contract can be reached at: docmedicalcontractsCr�doc1.wa.qov,
The contract manager for the DOC Participating Provider shall be City of Pasco Ambulance, Richa Sigdel,
Finance Director, sipdelr(c�pasco.wa.4ov, (509) 544-3065.
13. Documents Incorporated by Reference. Documents incorporated by reference can be obtained by
emailing the DOC Medical Contracts email, docmedicalcontracts doc1.wa. ov.
14. Severability.The provisions of the Agreement are severable. If any provision of the Agreement is held
invalid by any court that invalidity shall not affect the other provisions of this Agreement and the invalid
provision shall be considered modified to conform to existing law.
15. Signatures.The Provider agreement must be signed appropriately. If provider is a legal entity other
than a person,the person signing the Provider Agreement on behalf of the DOC Participating Provlder
warrants that he/she has legal authority to bind DOC Participating Provider. If a signed contract is not
returned within 30 days of receipt, claims will be processed at Medicaid rates.
16. Certification.This is to certify that I acknowledge that this Provider Agreement incorporates by reference
additional terms and conditions, including DOC Billing Instructions and fee schedules and Medical General
Terms and Conditions found using the links set forth in this Provider Agreement or by request to
docmedicalcontractsna, doc1.wa.gov. I agree to abide by the terms of this Provider Agreement including all
applicable federal and state statutes, rules, and policies.
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DOC PARTICIPATING PROVIDER DEPARTMENT OF CORRECTIONS
Digitally signed by Pumilia,
Pumilia, Michael M;�nae,�.coo��
� �-S �O —���' �/. (DO�\ Date:2021.12.23U26:46
V � � -08'00'
.�ontr�ctor's Full Legal Name) (Signature)
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�,;t i . � } , i
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(5ignature) ` +'� � Daryl Huntsinger
Y �u �'�`"1�' (Printed Name)
(Printed Name) Contracts Admixiistrator
-'��['. Iv�-Gr,liR�'� '�� (Title)
(Tifle) _ ---
�"��.3(�.C1< (Date)
(Date)
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