10 CCR 2505-10
FORM MED-11E ______________________ Pharmacy Name ______________________ Address Provider # ___________ Phone ________________ MED-11E (Rev. 6/84)
If approved as a participating provider, the applicant agrees:
1. To perform its pharmaceutical duties and obligations in conformances with provisions of Title XIX of the Social Security Act. all other relevant Federal laws and regulations, the Colorado Social Services Code 26-1-101, et. seq., C.R.S. 1973, as amended, and especially the Colorado Medical Assistance Act, 26-4-101 et seq., C.R.S. 1973, as amended, and all pertinent rules and regulations of the Colorado Department of Social Services, as all of the foregoing are in effect at the date of the approval of the provider's application to participate, or as they may later be amended.
2. To submit billings for authorized services and/or goods in accordance with the form, manner, and amounts provided by the aforementioned statutes and rules and regulations, and provide such services and goods on the basis of being compensated therefore in accordance with said rules and regulations. It is further agreed that in the event the applicant should receive payment for medical services, benefits, and/or goods in an amount in excess of that permitted by said law and rules and regulations, such excessive payments may be deducted from future payments on behalf of recipients otherwise payable to said applicant and/or recovery of such payments may be made otherwise at the option and discretion of the Department in accordance with its rules and regulations pertaining to recoveries or other legal means.
3. Not to submit bills, or otherwise attempt to collect from the recipients, relatives of recipients or others for medical services, benefits. and/or goods which are provided recipients by said Applicant under said medical program and which benefits, services, and/or goods are paid for by the Department. Said applicant further agrees to accept the payment under the said medical program as payment in full from the Department. This statement in no way relieves the applicant of responsibility as defined by law or rule or regulation to obtain payment from legally responsible persons, as is required by said law or rule or regulations.
4. To provide the Department with at least 30 days prior notice in the event of termination of participation in said medical program. (Termination of participation in the Medicaid Program, unless otherwise agreed to in writing by the Department, shall arise from voluntary or involuntary cessation of business; election to no longer participate; transfer of title and property to another party, corporation or partnership; any foreclosure, bankruptcy or receivership action.) However, this provision shall not apply in the case where an amendment to the rules of the Department is determined to be unacceptable to the eligible provider and for said reason he elects to discontinue participation 1n the program. In such event, the eligible provider shall forthwith notify the Department in writing of its intent to discontinue and the eligible provider and the Department shall forthwith negotiate the termination date. In no event shall said date be longer than 60 days from the effective date of the rule amendment.
5. To provide acceptable assurance to the Department of compliance with all Federal and State laws concerning discrimination and unfair employment practices, Including but not limited to Title VII of the Civil Rights Act of 1964. ss 504 of the Rehabilitation Act of 1973. and ss 24-34-301. C.R.S. 1973. as amended.
6. To give full cooperation to the Department and its duly authorized agents, in the administration of said medical program, and to maintain all records necessary to disclose the extent of services furnished to recipients as may be provided for in the said rules and regulations. The applicant further agrees to furnish representatives of the Department or its duly authorized agents, the Department of Health and Human Services or the Medicaid Fraud Control Unit, with all information regarding reimbursement claimed by the provider for furnishing services.
7. To abide by all processing or reimbursement requirements mandated by the Department of Social Services, either directly or through the Fiscal Agent. Fiscal Agent means an entity that processes or reimburses vendor claims for the Department.
8. That approval of this application by the Department authorizes the applicant to participate in the Medicaid program. However, neither this application nor its approval in any way alters, amends, or abrogates the legal responsibility of the applicant to execute a subcontract if it later agrees to provide medical services for Medicaid recipients through a Health Maintenance Organization or similar program.
9. That reimbursement by the Department to the applicant shall be made in accordance with the aforementioned Departmental rules and regulations as applied to the pharmacy claim form submitted by the provider.
10. Any violations of the above conditions may result in withdrawal of approval of this agreement to participate.
WHEREAS, the state has established a Colorado Medical Assistance Program, hereinafter referred to as the "program", by which to participate in Title XIX of the Social Security Act, hereinafter referred to as "Medicaid", through the Department; and WHEREAS, Contractor is licensed to operate a health care facility and is certified to operate a(n) (skilled) (intermediate) care facility through the Colorado Department of Health, pursuant to Medicaid and Medicare statutes and regulations, and desires to participate in the program and provide nursing services and care to eligible recipients; and WHEREAS, Contractor has demonstrated a quantitative and qualitative need for Contractor's services to its geographic region. consistent with comprehensive health planning goals and data, for the duration of this contract; and WHEREAS, as of the date of the execution of this contract, Contractor meets all other qualifications for participation in the program.
NOW THEREFORE, it is hereby agreed that 1. Contractor agrees to perform its duties and obligations hereunder in conformance with the provisions of Title XIX of the Social Security Act, other relevant federal law, all pertinent federal regulations promulgated pursuant to federal law, the Colorado Social Services Code, C.R.S. 1973. 26-i-101, et seq ., including the Colorado Medical Assistance Act, C.R.S. 1973, 26-4-101, et seq ., other relevant State law, the Colorado State Plan for medical assistance under Title XII, and all pertinent regulations of the Colorado Department of Social Services, as all the foregoing are in effect as of the date of the execution of this contract, or as they may later be amended.
2. This contract shall be for a term of commencing ___________________, and continuing to and including ______________________, unless earlier terminated by the Department under any of the following circumstances and for any of the following reasons:
(a) The Colorado Department of Health/United States Department of Health and Human Services has issued a conditional or short-term certification to contractor, dated ________________, 19_____, which specified the discovery of certain enumerated deficiencies in Contractor's facility. Unless said deficiencies are corrected on or before the ___________________ day of _______________, 19______, this agreement will automatically expire on said date.
(b) In the event that Contractor should lose its license or certification from the Department of Health, this contract shall terminate as of the date delicensure or decertification occurs.
(c) In the event that Contractor should lose its certification to participate in the Title XVIII Program, the Department shall take such action concerning Title XIX certification as is consistent with law and regulation.
(d) In the event that Contractor fails to comply with any of toe previsions of this contract or statutes, rules, or regulations described herein at paragraph 1, this contract shall be terminated for "good cause" as defined in Staff Manual, VIII, Provider Appeals and Hearings Section.
3. Records and Information (a) Contractor agrees to keep such records as are necessary to disclose the extent of the services provided to individuals receiving Colorado medical assistance. Such records shall include, but not be limited to, dietary services, nurse staffing, drug use, and financial records relating thereto.
(b) Contractor agrees to keep all records, plans and programs required by law and Department rules and regulations.
(c) Contractor agrees to keep all records pertaining to personal needs accounts, including but not limited to bank statements and bank books.
(d) Contractor agrees to keep all records of patient income received by Contractor and amounts due the Contractor on behalf of said patients.
(e) Contractor agrees to keep all personal needs and medical records and supporting documents at the nursing home facility operated by Contractor.
(f) Contractor agrees to make available, at all reasonable times during the contract period and five (5) years thereafter, all records and documents' pursuant to this agreement for inspection, audit, or reproduction by any authorized representative of the Department or appropriate federal agencies.
(g) Contractor shall provide the Department with the same complete and current ownership information required by and provided to the Department of Health pursuant to that Department's licensure regulations.
4. Contractor agrees to allow the Department of Health and Human Services, the Department and its designated and duly authorized representatives, including the Colorado Department of Health and the Medicaid Fraud Control Unit access to the health care facility at any time reasonable under the circumstances for purposes of conducting surveys, inspections, or audits as permitted or required by state and federal statutes and regulations and to allow medical review of the care received or being received by any recipient/patient who is or has been in the care and/or custody of the Contractor.
5. Contractor agrees to comply with the requirements of Title VI of the Civil lights Act of 1964.
6. Payment Rate (a) Contractor shall be reimbursed by the Department in such amounts as stay from time to time be set by the Colorado Department of Social Services pursuant to the Medicaid statute, the Colorado Medical Assistance Act, and the rules and regulations promulgated thereunder.
(b) Contractor agrees to accurately report to the Department on Form MED-13 (Financial and Statistical Report for Nursing Homes) all patient related expenses and all sources of income. The contractor shall, in addition to Its own signature, secure the signature of every accountant who in any way assists in the construction or completion of every Department Form NED-13 submitted to the Department.
(c) All billings for reimbursement shall be submitted in a form. Banner, and amount provided for by Department rules and shall contain such information as may he required by the Department.
(d) Contractor agrees to accurately report to the Department all money received on behalf of each patient. Contractor further agrees that no charges other than those made under the term of this contract and in accordance with law and Department rules shall be made to patients, their relatives, estates or any other person for Medicaid reimbursable services.
(e) All warrants endorsed by and presented to a bank by Contractor shall constitute payment in full, except when endorsed under good faith protest pursuant to Title IV, C.R.S. 1973.
(f) Contractor agrees to allow the Department or its designated representatives access to all information necessary to determine Contractor's reimbursement rate.
(g) In the event that under or over-payments were administratively made in error by the State to the Contractor, the parties agree that adjustment shall be made pursuant to procedures established by the Department.
(h) No advance payments shall be made by the Department pursuant to this contract. "Advance payments" are those made prior to the actual rendition of services by the Contractor.
7. Reapplication In the event that Contractor intends to apply for a new contract upon the termination of this contract. Contractor agrees to reapply for said new contract by completing and submitting its application upon an approved contract form (MED-11A) not less than sixty (60) days prior to the termination date of this agreement to the Department of Social Services, Division of Medical Assistance. The Division of Medical Assistance may. on its own initiative, provide blank reapplication forms to the Contractor prior to the termination date of this contract, provided that, failure to so provide shall not constitute the state's waiver of or an estoppel to the Contractor's responsibilities under this paragraph.
8. Notice of Change of Ownership or Premature Termination of Contract After the effective date of this contract, contractor shall notify this Department in writing of any change of ownership, as defined by Department regulations, not less than thirty (30) days prior to the effective date of that change. Contractor shall also provide the Department with sixty (60) days prior written notice of the date of termination of this contract in the event that date precedes the termination date described in paragraph 2 herein.
9. Declaration of Responsibility The Contractor agrees to furnish a current Declaration to the Department which shall list the specific individual(s) who is (are) authorized to execute agreements on behalf of the Contractor. The Declaration, attached are incorporated as Exhibit A to this contract, shall be signed and attested by an authorized corporate officer, a general partner, or the sole proprietor, as appropriate.
10. Surety Bond Where applicable pursuant to law, the Contractor agrees to purchase and maintain a surety bond in the amount of ten thousand dollars ($10,000) to protect its patients' personal needs trust funds. A current copy of such bond shall be provided to the Department and must be on file prior to contrast effective date.
(a) Contractor agrees to replace any shortages determined by audit of the personal needs trust fund by the Department.
(b) Contractor agrees to keep records of each patient's personal Deeds trust fund for a period of three (3) years from the date of the patient's discharge from the facility or until such records have been audited by the Department, whichever occurs last.
(c) Contractor agrees, in the event of cancellation of the current surety bond, to give the Department written notice within five (5) days of such cancellation. Contractor further agrees to undertake a new bonding agreement within ten (10) days of such cancellation.
(d) All bonding requirements set forth in this paragraph shall remain in effect until written release is made by the Department, pursuant to paragraph 15 of this contract.
11. Subcontracts No subcontract for management or operation services shall be made by the Contractor with any other party for furnishing any work or services under this contract without the prior written consent and approval of the Department. This prior written consent shall be granted within thirty (30) days of the Department's receipt of written request unless for good cause shown.
12. Prohibition of Assignment Neither the benefits nor the burdens of this contract may be assigned by the Contractor, either in whole or in part. The contract is void and automatically cancelled by the Department upon change of ownership of the health care facility or in the parties to the operational lease of a health care facility.
13. Insolvency The contract is voidable and subject to immediate cancellation by the Department upon the Contractor's insolvency, including the filing of proceedings in bankruptcy.
14. Transfer of Patient Property In the event of the termination or nonrenewal of this contract, all records, funds, and personal property of each patient-recipient, including personal needs trust monies, shall be transferred with the recipient to his/her new facility in a manner consistent with Department regulations. Any records not so transferred shall, at the written option of the State, either be transferred to the State or retained by the Contractor until written release by the State. All bonding shall remain in effect until written release is made by the State.
15. Integration This agreement is intended as the complete integration of all understandings between the parties. No prior or contemporaneous addition, deletion, or other amendment hereto shall have any force or effect whatsoever, unless embodied herein in writing. No subsequent novation, renewal, addition, deletion, or other amendment hereto shall have any force or effect unless embodied in a written contract executed and approved pursuant to the State Fiscal Rules.
16. Parties Relationship The parties of this Contract intend that the relationship between the completed by this Contract is that of independent contractor. No agent, employee, or servant of Contractor shall be or shall be deemed to be an employee, agent, or servant of Social Services. Contractor will be solely and entirely responsible for its acts and the acts of its agents, employees, servants and subcontractors during the performance of this contract.
17. Indemnification Contractor shall indemnify Social Services against all liability and loss, and against all claims and actions based upon or arising out of damage or injury, including death, to persons or property caused by or sustained in connection with the contractors performance of this Contract or by conditions created thereby, or based upon any violation of any statute, ordinance, or resolution are the defense of any such claims or actions.
18. Payment Payment pursuant to this Contract will be made as earned, in whole or in part, from available State funds for the purchase of nursing care services. It is agreed that the maximum amount of State funds available for the fiscal year is in the amount appropriated. The liability of the state, at any time, for such payments shall be limited to the unencumbered amount remaining of such funds.
19. Contingent Funding This contract is subject to and contingent upon the continuing availability of Federal funds for the purposes hereof.