HomeMy WebLinkAboutC03-335 Colorado Department of Health Care Policy and Financing – ACS State Healthcare, LLC
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Colorado Medical Assistance Program
PROVIDER PARTICIPATION AGREEMENT
This Provider Participation Agreement ("Agreement") is entered into by and between the Colorado Department of
Health Care Policy and Financing ("Department"), it's fiscal agent, ACS State Hea1thcare, LLC ("ACS"), and
Eagle County Health & Human Services
(Provider's Name)
(''Provider''), collectively ''the Parties." This Agreement is entered into in order to define Department expectations
of providers who perform services and submit billing, transactions, and/or data to the Colorado Medical Assistance
Program. This Agreement is also established to facilitate business transactions by electronically transmitting and
receiving data in agreed formats; to ensure the integrity, security, and confidentiality of the aforesaid data; and to
permit appropriate disclosure and use of such data as permitted by law. This Agreement is to be considered in
conjunction with the Provider Enrollment Form.
RECITALS
A. The Colorado Department of Health Care Policy and Financing is the single state agency responsible for
the administration of the Colorado Medical Assistance Program pursuant to Title XIX of the Social Security Act.
B. ACS has developed, on behalf of the Colorado Department of Health Care Policy and Financing, a
paperless transaction system that will process Colorado Medical Assistance Program electronic transactions
submitted through the designated electronic media.
C. ACS is the contracted Fiscal Agent for the Colorado Department of Health Care Policy and Financing,
which is responsible for administration of the Colorado Medical Assistance Program. Although ACS operates the
computer system translator through which electronic transactions flow, the Department retains ownership of the
data itself. Providers access the pipeline network through various means, over which the transmission of electronic
data occurs. Accordingly, providers are required to transport data to and from ACS.
D. Electronic transmission of any/aU data shall be in strict accordance with the standards set forth in this
Agreement and as defined by the Health Insurance Portability and Accountability Act and regulations promulgated
thereunder by the U.S. Department of Health and Human Services and other applici1ble laws, as amended.
E. This Agreement is subject to modification, revision, or termination according to changes in federal or state
laws, rules, or regulations. This Agreement will be deemed modified, revised, or terminated to comply with any
change on the effective date of such change.
F. This Agreement delineates the responsibilities of the Parties in regard to the Colorado Medical Assistance
Program. As consideration for acceptance as an enrolled provider in the Colorado Medical Assistance Program, the
Provider certifies and agrees to the terms and conditions set forth below.
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DEFINITIONS
For the purpose of this Agreement:
A. "Colorado Department of Health Care Policy and Financing" means the Colorado State governmental
agency responsible for the administration of the Colorado Medical Assistance Program pursuant to Title XIX of the
Social Security Act.
B. "Standard" is defined in 45 C.F.R. ~160.103.
C. "Provider" refers to any Health Care Provider as defined in 45 C.F.R. ~ 160.103 who submits or receives
data electronically to/from the Colorado Medical Assistance Program. ''Provider'' may also refer to health care
providers who submit paper claims to the Colorado Medical Assistance Program.
D. "Transaction" is defined in 45 C.F.R. ~160.103.
E. "Transactions and Code Set Regulations" mean those regulations governing the transmission of certain
health claims transactions as promulgated by the U.S. Department of Health and Human Services in 45 C.F.R. Parts
160 and 162.
PROVIDER PARTICIPATION
A. Provider will comply with all applicable provisions of the Social Security Act, as amended; federal or state
laws, regulations, and guidelines; and Department rules. Provider will limit the use or disclosure of
information/data concerning Colorado Medical Assistance Program clients to the pwposes directly connected with
the administration of the Colorado Medical Assistance Program.
B. Provider will accept full legal responsibility for all claims submitted under the Provider's number to the
Colorado Medical Assistance Program and will comply with all federal and state civil and criminal statutes,
regulations and rules relating to the delivery of benefits to eligible individuals and to the submission of claims for
such benefits. Provider understands that non-compliance could result in no payment for services rendered.
C. Provider will request payment only for those services which are medically necessary or considered covered
preventive services, and rendered personally by the Provider or rendered by qualified personnel under the
Provider's direct and personal supervision. Claims will be submitted only for those benefits provided by health
care personnel who meet the professional qualifications established by the State. Provider understands that any
misrepresentation or falsification by another may result in fine and/or imprisonment under state or federal law.
D. Provider will maintain records that fully and accurately disclose the nature and extent of benefits provided
to eligible clients/patients in accordance with the regulations of the Department. Provider will maintain licensure
and/or certification granted by the State licensing agency that regulates the services that are provided, and will
make disclosure of ownership and provide access to medical records and billing information to the Department, or
its designees, as required by federal and state laws and regulations.
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E. Provider records will be maintained for six (6) years unless an additional retention period is required under
state or federal regulations, such as an audit started before the six (6) year period ended or based on a specific
contract between the Provider and the Department.
F. The US Department of Health and Human Services, the Department, or the State Attorney General's
Medicaid Fraud Control Unit, or their designees, has the right to audit and confirm for any purpose any information
submitted by the Provider. Provider agrees to furnish information about submitted claims, any claim documentation
records, and original source documentation; including provider and patient signatures, medical and financial
records in the Provider's office or any other place, and any other relevant information upon request. Any and all
incorrect payments discovered as a result of an audit will be adjusted or fully recovered according to the applicable
provisions of the Social Security Act, as amended, federal or state laws, regulations, and guidelines.
G. Provider agrees to accept as payment in full, amounts paid in accordance with schedules established by the
Department. No supplemental charges will be billed to the client, except for amounts designated as co-payments by
the Department. Provider will not bill the client for any covered items or services that are reimbursable under the
rules and regulations of the Department, or for any items or services that are not reimbursable but would have been
had the Provider complied with the rules and regulations of the Department All payments received or applied from
any other sources will be recorded on the claim.
H. Provider certifies that items and services provided will be available without discrimination as to race, color,
religion, age (except as provided by law), sex, marital status, political affiliation, handicap, or national origin.
Provider hereby certifies compliance with Section 504 of the Rehabilitation Act of 1973 which provides that, .. no
otherwise qualified handicapped individual...shall, solely by reason ofhis/her handicap, be excluded from
participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving
federal financial assistance."
I. If, at any time from the date of this agreement, the Department determines that Provider has failed to
maintain compliance with any state or federal laws, rules, or regulations, Provider may be suspended from
participation in the Medical Assistance Program, and may be subjected to administrative actions authorized by
federal or state law or regulation, criminal investigation, and/or prosecution.
J. Department payment by electronic funds transfer (EFT) and advisement by deposit notice or remittance
statement represents Provider's confirmation that funds were accepted for services rendered and billed.
K. Provider, and person signing the claim or submitting electronic claims on Provider's behalf, understand that
failure to comply with any of the above in a true and accurate manner will result in any available administrative or
criminal action available to the Department, the State Attorney General's Medicaid Fraud Control Unit, or other
government agencies. The knowing submission of false claims or causing another to submit false claims may
subject the persons responsible to criminal charges, civil penalties, and/or forfeitures.
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GENERAL ELECTRONIC DATA INTERCHANGE TERMS AND CONDITIONS
(only applicable to those providers submitting and/or receiving data electronically)
A. The Parties agree to submit claims and exchange data electronically using only those approved Transaction
types and formats (versions) as selected by Provider within the Provider Enrollment Form.
B. For electronic claims, Provider will ensure that all required provider and patient signatures, including,
where applicable, appropriate signatures on behalf of the patient, and required physician certifications are on file in
the Provider's office.
C. Transactions/documents will be transmitted electronically either directly or through a contracted third-party
service provider, such as a vendor, billing agent, or clearinghouse. Provider may modify its election to use, not use,
or change a third-party service provider by updating the Provider Enrollment Form. Provider will be responsible
for the costs of any third-party service provider with which it contracts, and will ensure that any third-party service
provider contracted will properly institute and adhere to those procedures reasonably calculated to provide
appropriate levels of security for the authorized transmission of data, and protection from improper access. No
Party accepts responsibility for technical or operational difficulties that arise out of third-party service providers'
business obligations and requirements that undermine the Transaction exchange between Provider and ACS.
D. The Parties will not change any definition, data condition, or use of a data element or segment in a Standard
Transaction they exchange electronically, as per 45 C.F.R ~162.915.
E. The Parties will not add any data elements or segments to the maximum defined data set, as per 45 C.F.R.
~162.915.
F. The Parties will not use any code or data elements that are either marked ''not used" in a standard's
implementation specification or are not in the standard's implementation specification(s), as per 45 C.F.R.
~162.915.
G. The Parties will not change the meaning or intent ofa Standard's implementation specification(s), as per 45
C.F.R. ~162.915.
H. ACS will accept Transactions from Provider according to the Provider Enrollment Form, but may
subsequently deny a Transaction for further processing if the Transaction is not submitted using the data elements,
formats or Transaction types set forth in the Provider Enrollment Form. ACS may return Provider to a test status if
Provider repeatedly submits Transactions that do not meet the criteria set forth in the Provider Enrollment Form or
if Provider repeatedly submits inaccurate or incomplete Transactions to ACS.
I. Provider understands that ACS or others may request an exception from the Transaction and Code Set
Regulations from the U.S. Department of Health and Human Services. If an exception is granted, Provider will
participate fully with ACS in the testing, verification, and implementation of a modification to a Transaction
affected by the change.
J. Provider and ACS agree to keep open code sets being processed or used in this Agreement for at least the
current billing period or any appeal period, whichever is longer, as per 45 C.F.R. ~ 162.925(c)(2).
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K. Transactions are considered properly received only after accessibility is established at the designated
machine of the receiving Party. Once transmissions are properly received, the receiving Party will promptly
transmit an electronic acknowledgement that conclusively constitutes evidence of properly received Transactions.
Each Party will subject information to a virus check before transmission to the other Party.
L. ACS may publish data clarifications ("Companion Guides") to complement each Implementation Guide.
HIPAA Implementation Guides are available at http://www.wpc-edi.comlhipaa/HIPAA_40.asp. Companion
Guides are available from ACS ED! Gateway at http://coloradomedicaid.acs-inc.com
ELECTRONIC CONFIDENTIALITY, PRIVACY AND SECURITY
(only applicable to those providers submitting and/or receiving data electronically)
A. The Health Insurance Portability and Accountability Act of 1996 (HIP AA) Privacy and Security
Regulations (45 C.F.R. Parts 160 and 164) apply to all health plans, health care clearinghouses, and health care
providers that transmit protected health information in electronic transactions; and extends to any business associate
working on behalf of a covered entity. As such, it is expected that all Parties will implement and maintain
appropriate policies, procedures, and mechanisms to protect the privacy and security of protected health
information that is maintained by, and transmitted between, the Parties.
B. The Parties agree that any electronic protected health information furnished to one Party by any other Party
will be used only as authorized under the terms and conditions of this Agreement and the Provider Enrollment
Form, and may not be further disclosed. The Parties will establish appropriate administrative, technical,
procedural, and physical safeguards to ensure the confidentiality, integrity, and availability of all electronic
protected health information that is created, received, maintained, or transmitted as part of this Agreement.
Provider will obtain satisfactory assurance and documentation thereof, as required by 45 C.F.R. ~164.502(e), from
any business associate with whom it contracts, and any subcontractors thereof, that all protected health information
covered by this Agreement will be appropriately safeguarded.
C. Provider agrees that in the event the Department determines, or has a reasonable belief that Provider has
made or may have made disclosure of Colorado Medical Assistance Program client protected health information
that is not authorized by this Agreement, the Provider Enrollment Form, or other written Department authorization,
-the Department, in its sole discretion, may require ACS and/or Provider to: (a) promptly investigate and report to
the Department determinations regarding any alleged or actual unauthorized disclosure; (b) promptly resolve any
problems identified by the investigation; (c) submit a formal written response to an allegation of unauthorized
disclosure; (d) submit a corrective action plan with steps designed to prevent any future unauthorized disclosures;
and/or (e) return data to the Department.
ASSIGNMENT OF AGREEMENT
A. This Agreement is entered into solely between, and may be enforced only by the Parties. This Agreement
shall not be deemed to create any rights in third parties or to create any obligations of the Parties to any third party.
B. No Party may assign this Agreement without the prior written consent of the Department, and such consent
may not be unreasonably withheld.
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MODIFICATIONS
A. . This Agreement contains the entire agreement between the Parties and supersedes any previous
understanding, commitment or agreements, oral or written, concerning the electronic exchange of information/data.
Any change to this Agreement will be effective only when set forth in writing and executed by all Parties.
DISPUTES AND LIMITATION OF LIABILITY
A. This Agreement will be interpreted consistently with all applicable federal and state laws. In the event of a
conflict between applicable laws, the more stringent law will be applied. This Agreement and all disputes arising
from or relating in any way to the subject matter of this Agreement will be governed by and construed in
accordance with Colorado law, exclusive of conflicts of law principles. The exclusive jurisdiction for any legal
proceeding regarding this agreement shall be in the courts of the State of Colorado and the Parties hereby expressly
submit to such jurisdiction.
B. Parties will use reasonable efforts to assure that the information - data; electronic files and documents
supplied hereunder - are accurate. However, Provider shall indemnify, save, and hold harmless the Department, its
employees and agents, against any and all claims, damages, liability and court awards including costs, expenses,
and attomey fees incurred as a result of any act or omission by the Provider, or its employees, agents,
subcontractors, or assignees pursuant to the terms of this Agreement
C. Notwithstanding anything herein to the contrary, no term or condition shall be deemed, construed or
interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections, or provisions, of
the "Colorado Governmental Immunity Act", 24-10-101, et seq., C.R.S., as now or hereafter amended ("Immunity
Act"), nor of the Risk Management self-insurance statutes at 24-30-1501, et seq., C.R.S., as now or hereafter
amended ("Risk Management Act"). The Parties understand and agree that the liability of the State of Colorado, its
departments, institutions, agencies, boards, officials and employees is controlled and limited by the provisions of
the Immunity Act and the Risk Management Act, as now or hereafter amended. Any provision of this Agreement,
whether or not incorporated herein by reference, shall be controlled, limited, and otherwise modified so as to limit
any liability of the State to the above cited laws. In no event will the State be liable for any special, indirect, or
consequential damages, even if the State has been advised of the possibility thereof.
D. DISCLAIMER OF WARRANTIES. THE PARTIES HEREBY EXCLUDE ALL EXPRESS AND
IMPLIED WARRANTIES, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF
MERCHANTABILITY AND THE IMPLIED WARRANTY OF FITNESS FOR A PARTICULAR PURPOSE.
THERE ARE NO WARRANTIES WInCH EXTEND BEYOND THE DESCRIPTION OF THE FACE OF THIS
AGREEMENT.
E. Provider warrants and represents that at the time of entering into this Agreement, neither Provider nor any
of its employees, contractors, subcontractors or agents are identified on the HHS/OIG List of Excluded
IndividualslEntities (available at http://www.oig.hhs.gov/FRAUD/exc1usionsllistofexcluded.html). In the event
Provider or any employees, subcontractors or agents thereof becomes an ineligible person after entering into this
Agreement or otherwise fails to disclose its ineligible person status, Provider shall have an obligation to
immediately notify the Department of such ineligible person status and within ten days of such notice, remove such
individual from responsibility for, or involvement with the Providers business operations related to this Agreement.
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TERMINATION
A. This Agreement shall remain in effect until terminated by any Party with not less than thirty (30) days prior
written notice to the other Parties. Such notice shall specify the effective date of termination. In the event of a
material breach of this Agreement by Provider, as determined by the Department, the Department may terminate
the Agreement by giving written notice to the breaching Provider. The breaching Provider shall have thirty (30)
days to fully cure the breach. If the breach is not cured within thirty (30) days after the written notice is received by
the breaching Provider, this Agreement shall automatically and immediately terminate.
B. This Agreement may be terminated by the Department if the contract between the Department and ACS
expires or terminates. Provider enrollment records will survive assignment of a new Department fiscal agent unless
provider re-enrollment is explicitly initiated by the Department
TERM OF AGREEMENT
A. This Agreement is effective on the date signed below. This Agreement shall continue until terminated
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PROVIDER SIGNATURE PAGE
NO PROVIDER ENROLLMENT FORM, PROVIDER AUTHORIZATION FORM (if applicable),
OR PROVIDER PARTICIPATION AGREEMENT WILL BE PROCESSED WITHOUT
COMPLETION OF THIS PAGE
I certify by my signature below that I am fully authorized to sign and execute this Agreement on behalf of
Provider; and that I have read, understand, certify, and agree to all the statements made above in all parts
of this Provider Emollment Form, Provider Authorization Form (if applicable), and Provider Participation
Agreement. I further understand that any false claims, statements, documents, or concealment of material
fact may be grounds for termination as a Colorado Medical Assistance Program Provider, and/or may be
prosecuted :under applicable federal and state laws.
Provider
Signature
By:
Name:
'-Miehael L' GallaghH l OJV'\. G _ 6~~on...Q_
~.-o-\~~
Chairman; Eagle County Board of Commissioners
Title:
Date:
November 18, 2003
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