HomeMy WebLinkAboutAgreement A-18-584 with Advanced Medical Management.pdf Agreement No. 18-584
1 AGREEMENT
2
3 THIS AGREEMENT is made and entered into this 9th day of October, 2018, by
4 and between the COUNTY OF FRESNO, a Political Subdivision of the State of California,
5 hereinafter referred to as "COUNTY", and Advanced Medical Management Inc., a California
6 corporation whose address is 5000 Airport Plaza Dr., Suite 150, Long Beach CA 90815,
7 hereinafter referred to as "CONTRACTOR".
8 WITNESSETH:
9 WHEREAS, COUNTY established the Emergency Medical Services Fund (EMSF)
10 Program in accordance with California Health and Safety Code Section 1797.98a; and
11 WHEREAS, a portion of the EMSF is designated as the Physicians' Allocation; and,
12 WHEREAS, COUNTY issued Request for Quotation #18-013 for fiscal intermediary
13 services for the EMSF and CONTRACTOR was the successful bidder; and,
14 WHEREAS, the parties wish to provide for equitable reimbursement of those providing
15 EMSF Program services with a minimum of administrative costs; and,
16 WHEREAS, the parties desire to state their respective rights and responsibilities related
17 to providing, claiming, and reimbursing EMSF Program services.
18 WHEREAS, COUNTY wishes to contract with CONTRACTOR for the provision of Fiscal
19 Intermediary Services for Emergency Medical Services Fund Program services described
20 herein to the residents of Fresno County; and
21 WHEREAS, CONTRACTOR is agreeable to the rendering of such services on the terms
22 and conditions hereinafter set forth:
23 NOW, THEREFORE, in consideration of the mutual covenants, terms and conditions herein
24 contained, the parties hereto agree as follows:
25 1. OBLIGATIONS OF THE CONTRACTOR
26 A. CONTRACTOR shall provide fiscal intermediary services as outlined in
27 Exhibit A, attached hereto and by this reference incorporated herein.
28 2. OBLIGATIONS OF THE COUNTY
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1 A. COUNTY shall provide general oversight of the program including
2 appropriate financial and contract monitoring and review and analysis of data gathered and
3 reported.
4 B. COUNTY shall also provide evaluation and standards assurance of the
5 program.
6 3. TERM
7 The term of this Agreement shall be for a period of three (3) years,
8 commencing on October 9, 2018 through and including June 30, 2021. This Agreement may be
9 extended for two (2) additional consecutive twelve (12) month periods upon written approval of
10 both parties no later than thirty (30) days prior to the first day of the next twelve (12) month
11 extension period. The Director of the Department of Public Health or his or her designee is
12 authorized to execute such written approval on behalf of COUNTY based on CONTRACTOR'S
13 satisfactory performance.
14 4. TERMINATION
15 A. Non-Allocation of Funds - The terms of this Agreement, and the services to
16 be provided hereunder, are contingent on the approval of funds by the appropriating government
17 agency. Should sufficient funds not be allocated, the services provided may be modified, or this
18 Agreement terminated, at any time by giving the CONTRACTOR thirty (30) days advance written
19 notice.
20 B. Breach of Contract - The COUNTY may immediately suspend or terminate
21 this Agreement in whole or in part, where in the determination of the COUNTY there is:
22 1) An illegal or improper use of funds;
23 2) A failure to comply with any term of this Agreement;
24 3) A substantially incorrect or incomplete report submitted to the
25 COUNTY;
26 4) Improperly performed service.
27 In no event shall any payment by the COUNTY constitute a waiver by the COUNTY
28 of any breach of this Agreement or any default which may then exist on the part of the
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1 CONTRACTOR. Neither shall such payment impair or prejudice any remedy available to the
2 COUNTY with respect to the breach or default. The COUNTY shall have the right to demand of
3 the CONTRACTOR the repayment to the COUNTY of any funds disbursed to the CONTRACTOR
4 under this Agreement, which in the judgment of the COUNTY were not expended in accordance
5 with the terms of this Agreement. The CONTRACTOR shall promptly refund any such funds upon
6 demand.
7 C. Without Cause - Under circumstances other than those set forth above,
8 this Agreement may be terminated by COUNTY upon the giving of thirty (30) days advance written
9 notice of an intention to terminate to CONTRACTOR.
10 5. COMPENSATION/INVOICING: COUNTY agrees to pay CONTRACTOR and
11 CONTRACTOR agrees to receive compensation as follows:
12 A. $5.00 per Claim adjudicated by CONTRACTOR from Physicians eligible to
13 submit claims.
14 B. Ad hoc reporting, consulting, and other administrative services provided
15 upon written request of COUNTY shall be subject to a $200/hour fee,
16 C. The period of July 1, 2018 through June 30, 2019 shall include an
17 additional Twenty-Five Thousand and 00/100 Dollars ($25,000) lump sum implementation fee
18 payable to CONTRACTOR.
19 D. The total of all compensation paid to CONTRACTOR in a given fiscal year,
20 shall not exceed 9.5 percent of all deposits to and appropriations for the Emergency Medical
21 Services Fund for each fiscal year. To the extent that the total of all compensation paid is less
22 than the 9.5 percent maximum, the balance shall remain in the Physicians' Allocation for
23 distribution to physicians.
24 E. For fiscal intermediary services provided by CONTRACTOR in accordance
25 with the Agreement, COUNTY shall, upon receipt of an appropriate invoice, pay CONTRACTOR
26 monthly, in arrears.
27 F. For purposes of reimbursement to CONTRACTOR, a Claim shall be
28 reimbursed regardless of the adjudication result, including claims that are paid, denied, duplicated,
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1 and re-submitted.
2 G. COUNTY shall pay CONTRACTOR quarterly in an amount not to exceed
3 the share of EMSF revenues received by COUNTY allocated for the reimbursement of physician
4 claims. Such funds shall be immediately deposited by CONTRACTOR into an interest-bearing
5 account controlled by CONTRACTOR for reimbursement of Physician Claims received on or after
6 July 1st of each fiscal year.
7 H. If CONTRACTOR determines that the fees to maintain an interest-bearing
8 account exceed the projected interest to be earned, CONTRACTOR shall recommend to
9 COUNTY that such funds be maintained in a non-interest-bearing account. Approval of the
10 recommendation shall be at the sole discretion of COUNTY.
11 I. Upon determination by CONTRACTOR that the account requires additional
12 funds for reimbursement of claims authorized in accordance with the Agreement, CONTRACTOR
13 shall submit a supplemental invoice to COUNTY, together with any documentation that may be
14 required by COUNTY.
15 J. Monthly, CONTRACTOR shall forward COUNTY an electronic copy of the
16 most current bank statement(s) and reconciliation with respect to all monies disbursed pursuant to
17 the Agreement.
18 K. All billings to COUNTY shall be supported by source documentation
19 including, but not limited to, provider claims, ledgers, journals, bank statements, canceled checks,
20 and records of services paid. In support of billing, CONTRACTOR shall submit a Claims
21 Processed Report in an electronic format acceptable to COUNTY.
22 L. For the period of October 1, 2018 through June 30, 2019, the amount of
23 this Agreement shall not exceed One Million Six Hundred Thousand and 00/100 Dollars
24 ($1,600,000.00). The maximum amount for this period is larger than that of subsequent periods
25 due to COUNTY claims backlog to be resolved by CONTRACTOR during the period.
26 M. For the period of July 1, 2019 through June 30, 2020 the amount of this
27 Agreement shall not exceed Five Hundred Thirty Thousand and 00/100 Dollars ($530,000.00).
28 N. For the period of July 1, 2020 through June 30, 2021 the amount of this
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1 Agreement shall not exceed Five Hundred Thirty Thousand and 00/100 Dollars ($530,000.00)
2 O. For the period of July 1, 2021 through June 30, 2022 the amount of this
3 Agreement shall not exceed Five Hundred Thirty Thousand and 00/100 Dollars ($530,000.00)
4 P. For the period of July 1, 2022 through June 30, 2023 the amount of this
5 Agreement shall not exceed Five Hundred Thirty Thousand and 00/100 Dollars ($530,000.00).
6 Q. The maximum monetary compensation payable under the agreement shall
7 not exceed Three Million Seven Hundred Twenty Thousand and 00/100 Dollars ($3,720,000
8 the full five (5) year term.
9 6. INDEPENDENT CONTRACTOR: In performance of the work, duties and
10 obligations assumed by CONTRACTOR under this Agreement, it is mutually understood and
11 agreed that CONTRACTOR, including any and all of the CONTRACTOR'S officers, agents, and
12 employees will at all times be acting and performing as an independent contractor, and shall act in
13 an independent capacity and not as an officer, agent, servant, employee, joint venturer, partner, or
14 associate of the COUNTY. Furthermore, COUNTY shall have no right to control or supervise or
15 direct the manner or method by which CONTRACTOR shall perform its work and function.
16 However, COUNTY shall retain the right to administer this Agreement so as to verify that
17 CONTRACTOR is performing its obligations in accordance with the terms and conditions thereof.
18 CONTRACTOR and COUNTY shall comply with all applicable provisions of
19 law and the rules and regulations, if any, of governmental authorities having jurisdiction over
20 matters the subject thereof.
21 Because of its status as an independent contractor, CONTRACTOR shall have
22 absolutely no right to employment rights and benefits available to COUNTY employees.
23 CONTRACTOR shall be solely liable and responsible for providing to, or on behalf of, its
24 employees all legally-required employee benefits. In addition, CONTRACTOR shall be solely
25 responsible and save COUNTY harmless from all matters relating to payment of
26 CONTRACTOR'S employees, including compliance with Social Security withholding and all other
27 regulations governing such matters. It is acknowledged that during the term of this Agreement,
28 CONTRACTOR may be providing services to others unrelated to the COUNTY or to this
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1 Agreement.
2 7. MODIFICATION: Any matters of this Agreement may be modified from time
3 to time by the written consent of all the parties without, in any way, affecting the remainder.
4 8. NON-ASSIGNMENT: Neither party shall assign, transfer or sub-contract this
5 Agreement nor their rights or duties under this Agreement without the prior written consent of the
6 other party.
7 9. HOLD HARMLESS: CONTRACTOR agrees to indemnify, save, hold
8 harmless, and at COUNTY'S request, defend the COUNTY, its officers, agents, and employees
9 from any and all costs and expenses, damages, liabilities, claims, and losses occurring or
10 resulting to COUNTY in connection with the performance, or failure to perform, by
11 CONTRACTOR, its officers, agents, or employees under this Agreement, and from any and all
12 costs and expenses, damages, liabilities, claims, and losses occurring or resulting to any person,
13 firm, or corporation who may be injured or damaged by the performance, or failure to perform,
14 of CONTRACTOR, its officers, agents, or employees under this Agreement.
15 10. INSURANCE
16 Without limiting the COUNTY's right to obtain indemnification from
17 CONTRACTOR or any third parties, CONTRACTOR, at its sole expense, shall maintain in full
18 force and effect, the following insurance policies or a program of self-insurance, including but not
19 limited to, an insurance pooling arrangement or Joint Powers Agreement (JPA) throughout the
20 term of the Agreement:
21 A. Commercial General Liability
22 Commercial General Liability Insurance with limits of not less than Two Million Dollars
23 ($2,000,000.00) per occurrence and an annual aggregate of Four Million Dollars ($4,000,000.00). This
24 policy shall be issued on a per occurrence basis. COUNTY may require specific coverages including
25 completed operations, products liability, contractual liability, Explosion-Collapse-Underground, fire legal
26 liability or any other liability insurance deemed necessary because of the nature of this contract.
27 B. Automobile Liability
28 Comprehensive Automobile Liability Insurance with limits of not less than One Million
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1 Dollars ($1,000,000.00) per accident for bodily injury and for property damages. Coverage should include
2 any auto used in connection with this Agreement.
3 C. Professional Liability
4 If CONTRACTOR employs licensed professional staff, (e.g., Ph.D., R.N., L.C.S.W.,
5 M.F.C.C.) in providing services, Professional Liability Insurance with limits of not less than One Million
6 Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00) annual aggregate.
7 D. Worker's Compensation
8 A policy of Worker's Compensation insurance as may be required by the
9 California Labor Code.
10 CONTRACTOR shall obtain endorsements to the Commercial General Liability
11 insurance naming the County of Fresno, its officers, agents, and employees, individually and
12 collectively, as additional insured, but only insofar as the operations under this Agreement are
13 concerned. Such coverage for additional insured shall apply as primary insurance and any other
14 insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees shall be
15 excess only and not contributing with insurance provided under CONTRACTOR's policies herein.
16 This insurance shall not be cancelled or changed without a minimum of thirty (30) days advance
17 written notice given to COUNTY.
18 Within Thirty (30) days from the date CONTRACTOR signs and executes this
19 Agreement, CONTRACTOR shall provide certificates of insurance and endorsement as stated
20 above for all of the foregoing policies, as required herein, to the County of Fresno, (Name and
21 Address of the official who will administer this contract), stating that such insurance coverage have
22 been obtained and are in full force; that the County of Fresno, its officers, agents and employees
23 will not be responsible for any premiums on the policies; that such Commercial General Liability
24 insurance names the County of Fresno, its officers, agents and employees, individually and
25 collectively, as additional insured, but only insofar as the operations under this Agreement are
26 concerned; that such coverage for additional insured shall apply as primary insurance and any
27 other insurance, or self-insurance, maintained by COUNTY, its officers, agents and employees,
28 shall be excess only and not contributing with insurance provided under CONTRACTOR's policies
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1 herein; and that this insurance shall not be cancelled or changed without a minimum of thirty (30)
2 days advance, written notice given to COUNTY.
3 In the event CONTRACTOR fails to keep in effect at all times insurance
4 coverage as herein provided, the COUNTY may, in addition to other remedies it may have,
5 suspend or terminate this Agreement upon the occurrence of such event.
6 All policies shall be issued by admitted insurers licensed to do business in the
7 State of California, and such insurance shall be purchased from companies possessing a current
8 A.M. Best, Inc. rating of A FSC VII or better.
9 11. AUDITS AND INSPECTIONS: The CONTRACTOR shall at any time during
10 business hours, and as often as the COUNTY may deem necessary, make available to the
11 COUNTY for examination all of its records and data with respect to the matters covered by this
12 Agreement. The CONTRACTOR shall, upon request by the COUNTY, permit the COUNTY to
13 audit and inspect all of such records and data necessary to ensure CONTRACTOR'S compliance
14 with the terms of this Agreement.
15 If this Agreement exceeds ten thousand dollars ($10,000.00), CONTRACTOR
16 shall be subject to the examination and audit of the Auditor General for a period of three (3) years
17 after final payment under contract (Government Code Section 8546.7).
18 12. NOTICES: The persons and their addresses having authority to give and
19 receive notices under this Agreement include the following:
20 COUNTY CONTRACTOR
COUNTY OF FRESNO Advanced Medical Manaaement
21 Department of Public Health 5000 Airport Plaza Drive, Suite 150
22 1221 Fulton Street Lona Beach, CA 90815
Fresno, CA 93721
23 All notices between the COUNTY and CONTRACTOR provided for or
24 permitted under this Agreement must be in writing and delivered either by personal service, by
25 first-class United States mail, by an overnight commercial courier service, or by telephonic
26 facsimile transmission. A notice delivered by personal service is effective upon service to the
27 recipient. A notice delivered by first-class United States mail is effective three COUNTY business
28 days after deposit in the United States mail, postage prepaid, addressed to the recipient. A notice
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1 delivered by an overnight commercial courier service is effective one COUNTY business day after
2 deposit with the overnight commercial courier service, delivery fees prepaid, with delivery
3 instructions given for next day delivery, addressed to the recipient. A notice delivered by
4 telephonic facsimile is effective when transmission to the recipient is completed (but, if such
5 transmission is completed outside of COUNTY business hours, then such delivery shall be
6 deemed to be effective at the next beginning of a COUNTY business day), provided that the
7 sender maintains a machine record of the completed transmission. For all claims arising out of or
8 related to this Agreement, nothing in this section establishes, waives, or modifies any claims
9 presentation requirements or procedures provided by law, including but not limited to the
10 Government Claims Act (Division 3.6 of Title 1 of the Government Code, beginning with section
11 810).
12 13. GOVERNING LAW: Venue for any action arising out of or related to this
13 Agreement shall only be in Fresno County, California.
14 The rights and obligations of the parties and all interpretation and performance
15 of this Agreement shall be governed in all respects by the laws of the State of California.
16 14. DISCLOSURE OF SELF-DEALING TRANSACTIONS
17 This provision is only applicable if the CONTRACTOR is operating as a
18 corporation (a for-profit or non-profit corporation) or if during the term of the agreement, the
19 CONTRACTOR changes its status to operate as a corporation.
20 Members of the CONTRACTOR's Board of Directors shall disclose any self-
21 dealing transactions that they are a party to while CONTRACTOR is providing goods or
22 performing services under this agreement. A self-dealing transaction shall mean a transaction
23 to which the CONTRACTOR is a party and in which one or more of its directors has a material
24 financial interest. Members of the Board of Directors shall disclose any self-dealing
25 transactions that they are a party to by completing and signing a Self-Dealing Transaction
26 Disclosure Form, attached hereto as Exhibit B and incorporated herein by reference, and
27 submitting it to the COUNTY prior to commencing with the self-dealing transaction or
28 immediately thereafter.
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1 15. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
2 A. The parties to this Agreement shall be in strict conformance with all
3 applicable Federal and State of California laws and regulations, including but not limited to
4 Sections 5328, 10850, and 14100.2 et seq. of the Welfare and Institutions Code, Sections 2.1
5 and 431.300 et seq. of Title 42, Code of Federal Regulations (CFR), Section 56 et seq. of the
6 California Civil Code and the Health Insurance Portability and Accountability Act (HIPAA),
7 including but not limited to Section 1320 D et seq. of Title 42, United States Code (USC) and its
8 implementing regulations, including, but not limited to Title 45, CFR, Sections 142, 160, 162, and
9 164, The Health Information Technology for Economic and Clinical Health Act (HITECH)
10 regarding the confidentiality and security of patient information, and the Genetic Information
11 Nondiscrimination Act (GINA) of 2008 regarding the confidentiality of genetic information.
12 Except as otherwise provided in this Agreement, CONTRACTOR, as a
13 Business Associate of COUNTY, may use or disclose Protected Health Information (PHI) to
14 perform functions, activities or services for or on behalf of COUNTY, as specified in this
15 Agreement, provided that such use or disclosure shall not violate the Health Insurance Portability
16 and Accountability Act (HIPAA), USC 1320d et seq. The uses and disclosures of PHI may not be
17 more expansive than those applicable to COUNTY, as the "Covered Entity" under the HIPAA
18 Privacy Rule (45 CFR 164.500 et seq.), except as authorized for management, administrative or
19 legal responsibilities of the Business Associate.
20 B. CONTRACTOR, including its subcontractors and employees, shall
21 protect, from unauthorized access, use, or disclosure of names and other identifying information,
22 including genetic information, concerning persons receiving services pursuant to this Agreement,
23 except where permitted in order to carry out data aggregation purposes for health care
24 operations [45 CFR Sections 164.504 (e)(2)(i), 164.504 (3)(2)(ii)(A), and 164.504 (e)(4)(i)] This
25 pertains to any and all persons receiving services pursuant to a COUNTY funded program. This
26 requirement applies to electronic PHI. CONTRACTOR shall not use such identifying information
27 or genetic information for any purpose other than carrying out CONTRACTOR's obligations
28 under this Agreement.
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1 C. CONTRACTOR, including its subcontractors and employees, shall not
2 disclose any such identifying information or genetic information to any person or entity, except as
3 otherwise specifically permitted by this Agreement, authorized by Subpart E of 45 CFR Part 164
4 or other law, required by the Secretary, or authorized by the client/patient in writing. In using or
5 disclosing PHI that is permitted by this Agreement or authorized by law, CONTRACTOR shall
6 make reasonable efforts to limit PHI to the minimum necessary to accomplish intended purpose
7 of use, disclosure or request.
8 D. For purposes of the above sections, identifying information shall include,
9 but not be limited to name, identifying number, symbol, or other identifying particular assigned to
10 the individual, such as finger or voice print, or photograph.
11 E. For purposes of the above sections, genetic information shall include
12 genetic tests of family members of an individual or individual, manifestation of disease or disorder
13 of family members of an individual, or any request for or receipt of, genetic services by individual
14 or family members. Family member means a dependent or any person who is first, second, third,
15 or fourth degree relative.
16 F. CONTRACTOR shall provide access, at the request of COUNTY, and
17 in the time and manner designated by COUNTY, to PHI in a designated record set (as defined
18 in 45 CFR Section 164.501), to an individual or to COUNTY in order to meet the requirements
19 of 45 CFR Section 164.524 regarding access by individuals to their PHI. With respect to
20 individual requests, access shall be provided within thirty (30) days from request. Access may
21 be extended if CONTRACTOR cannot provide access and provides individual with the reasons
22 for the delay and the date when access may be granted. PHI shall be provided in the form
23 and format requested by the individual or COUNTY.
24 CONTRACTOR shall make any amendment(s) to PHI in a designated
25 record set at the request of COUNTY or individual, and in the time and manner designated by
26 COUNTY in accordance with 45 CFR Section 164.526.
27 CONTRACTOR shall provide to COUNTY or to an individual, in a time and
28 manner designated by COUNTY, information collected in accordance with 45 CFR Section
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1 164.528, to permit COUNTY to respond to a request by the individual for an accounting of
2 disclosures of PHI in accordance with 45 CFR Section 164.528.
3 G. CONTRACTOR shall report to COUNTY, in writing, any knowledge or
4 reasonable belief that there has been unauthorized access, viewing, use, disclosure, security
5 incident, or breach of unsecured PHI not permitted by this Agreement of which it becomes aware,
6 immediately and without reasonable delay and in no case later than two (2) business days of
7 discovery. Immediate notification shall be made to COUNTY's Information Security Officer and
8 Privacy Officer and COUNTY's DPH HIPAA Representative, within two (2) business days of
9 discovery. The notification shall include, to the extent possible, the identification of each
10 individual whose unsecured PHI has been, or is reasonably believed to have been, accessed,
11 acquired, used, disclosed, or breached. CONTRACTOR shall take prompt corrective action to
12 cure any deficiencies and any action pertaining to such unauthorized disclosure required by
13 applicable Federal and State Laws and regulations. CONTRACTOR shall investigate such
14 breach and is responsible for all notifications required by law and regulation or deemed
15 necessary by COUNTY and shall provide a written report of the investigation and reporting
16 required to COUNTY's Information Security Officer and Privacy Officer and COUNTY's DPH
17 HIPAA Representative. This written investigation and description of any reporting necessary
18 shall be postmarked within the thirty (30) working days of the discovery of the breach to the
19 addresses below:
20 County of Fresno County of Fresno County of Fresno
21 Dept. of Public Health Dept. of Public Health Information Technology Services
22 HIPAA Representative Privacy Officer Information Security Officer
(559) 600-6439 (559) 600-6405 (559) 600-5800
23 P.O. Box 11867 P.O. Box 11867 333 W. Pontiac Way
Fresno, CA 93775 Fresno, CA 93775 Clovis, CA 93612
24
25 H. CONTRACTOR shall make its internal practices, books, and records
26 relating to the use and disclosure of PHI received from COUNTY, or created or received by the
27 CONTRACTOR on behalf of COUNTY, in compliance with HIPAA's Privacy Rule, including, but
28 not limited to the requirements set forth in Title 45, CFR, Sections 160 and 164. CONTRACTOR
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1 shall make its internal practices, books, and records relating to the use and disclosure of PHI
2 received from COUNTY, or created or received by the CONTRACTOR on behalf of COUNTY,
3 available to the United States Department of Health and Human Services (Secretary) upon
4 demand.
5 CONTRACTOR shall cooperate with the compliance and investigation
6 reviews conducted by the Secretary. PHI access to the Secretary must be provided during the
7 CONTRACTOR's normal business hours, however, upon exigent circumstances access at any
8 time must be granted. Upon the Secretary's compliance or investigation review, if PHI is
9 unavailable to CONTRACTOR and in possession of a Subcontractor, it must certify efforts to
10 obtain the information to the Secretary.
11 I. Safeguards
12 CONTRACTOR shall implement administrative, physical, and technical
13 safeguards as required by the HIPAA Security Rule, Subpart C of 45 CFR 164, that reasonably
14 and appropriately protect the confidentiality, integrity, and availability of PHI, including electronic
15 PHI, that it creates, receives, maintains or transmits on behalf of COUNTY and to prevent
16 unauthorized access, viewing, use, disclosure, or breach of PHI other than as provided for by this
17 Agreement. CONTRACTOR shall conduct an accurate and thorough assessment of the potential
18 risks and vulnerabilities to the confidential, integrity and availaibility of electronic PHI.
19 CONTRACTOR shall develop and maintain a written information privacy and security program
20 that includes administrative, technical and physical safeguards appropriate to the size and
21 complexity of CONTRACTOR's operations and the nature and scope of its activities. Upon
22 COUNTY's request, CONTRACTOR shall provide COUNTY with information concerning such
23 safeguards.
24 CONTRACTOR shall implement strong access controls and other security
25 safeguards and precautions in order to restrict logical and physical access to confidential,
26 personal (e.g., PHI) or sensitive data to authorized users only. Said safeguards and precautions
27 shall include the following administrative and technical password controls for all systems used to
28 process or store confidential, personal, or sensitive data:
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1 1. Passwords must not be:
2 a. Shared or written down where they are accessible or
3 recognizable by anyone else; such as taped to computer screens, stored under keyboards, or
4 visible in a work area;
5 b. A dictionary word; or
6 C. Stored in clear text
7 2. Passwords must be:
8 a. Eight (8) characters or more in length;
9 b. Changed every ninety (90) days;
10 C. Changed immediately if revealed or compromised; and
11 d. Composed of characters from at least three (3) of the
12 following four (4) groups from the standard keyboard:
13 1) Upper case letters (A-Z);
14 2) Lowercase letters (a-z);
15 3) Arabic numerals (0 through 9); and
16 4) Non-alphanumeric characters (punctuation symbols).
17 CONTRACTOR shall implement the following security controls on each
18 workstation or portable computing device (e.g., laptop computer) containing confidential,
19 personal, or sensitive data:
20 1. Network-based firewall and/or personal firewall;
21 2. Continuously updated anti-virus software; and
22 3. Patch management process including installation of all operating
23 system/software vendor security patches.
24 CONTRACTOR shall utilize a commercial encryption solution that has
25 received FIPS 140-2 validation to encrypt all confidential, personal, or sensitive data stored on
26 portable electronic media (including, but not limited to, compact disks and thumb drives) and
27 on portable computing devices (including, but not limited to, laptop and notebook computers).
28 CONTRACTOR shall not transmit confidential, personal, or sensitive data
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1 via e-mail or other internet transport protocol unless the data is encrypted by a solution that
2 has been validated by the National Institute of Standards and Technology (NIST) as
3 conforming to the Advanced Encryption Standard (AES) Algorithm. CONTRACTOR must apply
4 appropriate sanctions against its employees who fail to comply with these safeguards. CONTRACTOR
5 must adopt procedures for terminating access to PHI when employment of employee ends.
6 J. Mitigation of Harmful Effects
7 CONTRACTOR shall mitigate, to the extent practicable, any harmful effect
8 that is suspected or known to CONTRACTOR of an unauthorized access, viewing, use,
9 disclosure, or breach of PHI by CONTRACTOR or its subcontractors in violation of the
10 requirements of these provisions. CONTRACTOR must document suspected or known
11 harmful effects and the outcome.
12 K. CONTRACTOR's Subcontractors
13 CONTRACTOR shall ensure that any of its contractors, including
14 subcontractors, if applicable, to whom CONTRACTOR provides PHI received from or created
15 or received by CONTRACTOR on behalf of COUNTY, agree to the same restrictions,
16 safeguards, and conditions that apply to CONTRACTOR with respect to such PHI and to
17 incorporate, when applicable, the relevant provisions of these provisions into each subcontract
18 or sub-award to such agents or subcontractors..
19 L. Employee Training and Discipline
20 CONTRACTOR shall train and use reasonable measures to ensure
21 compliance with the requirements of these provisions by employees who assist in the
22 performance of functions or activities on behalf of COUNTY under this Agreement and use or
23 disclose PHI and discipline such employees who intentionally violate any provisions of these
24 provisions, including termination of employment.
25 M. Termination for Cause
26 Upon COUNTY's knowledge of a material breach of these provisions by
27 CONTRACTOR, COUNTY shall either:
28 1. Provide an opportunity for CONTRACTOR to cure the breach
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1 or end the violation and terminate this Agreement if CONTRACTOR does not cure the breach
2 or end the violation within the time specified by COUNTY; or
3 2. Immediately terminate this Agreement if CONTRACTOR has
4 breached a material term of these provisions and cure is not possible.
5 3. If neither cure nor termination is feasible, the COUNTY's Privacy
6 Officer shall report the violation to the Secretary of the U.S. Department of Health and Human
7 Services.
8 N. Judicial or Administrative Proceedings
9 COUNTY may terminate this Agreement in accordance with the terms and
10 conditions of this Agreement as written hereinabove, if: (1) CONTRACTOR is found guilty in a
11 criminal proceeding for a violation of the HIPAA Privacy or Security Laws or the HITECH Act;
12 or (2) a finding or stipulation that the CONTRACTOR has violated a privacy or security
13 standard or requirement of the HITECH Act, HIPAA or other security or privacy laws in an
14 administrative or civil proceeding in which the CONTRACTOR is a party.
15 O. Effect of Termination
16 Upon termination or expiration of this Agreement for any reason,
17 CONTRACTOR shall return or destroy all PHI received from COUNTY (or created or received
18 by CONTRACTOR on behalf of COUNTY) that CONTRACTOR still maintains in any form, and
19 shall retain no copies of such PHI. If return or destruction of PHI is not feasible, it shall
20 continue to extend the protections of these provisions to such information, and limit further use
21 of such PHI to those purposes that make the return or destruction of such PHI infeasible. This
22 provision shall apply to PHI that is in the possession of subcontractors or agents, if applicable,
23 of CONTRACTOR. If CONTRACTOR destroys the PHI data, a certification of date and time of
24 destruction shall be provided to the COUNTY by CONTRACTOR.
25 P. Disclaimer
26 COUNTY makes no warranty or representation that compliance by
27 CONTRACTOR with these provisions, the HITECH Act, HIPAA or the HIPAA regulations will
28 be adequate or satisfactory for CONTRACTOR's own purposes or that any information in
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1 CONTRACTOR's possession or control, or transmitted or received by CONTRACTOR, is or
2 will be secure from unauthorized access, viewing, use, disclosure, or breach. CONTRACTOR
3 is solely responsible for all decisions made by CONTRACTOR regarding the safeguarding of
4 PHI.
5 Q. Amendment
6 The parties acknowledge that Federal and State laws relating to electronic
7 data security and privacy are rapidly evolving and that amendment of these provisions may be
8 required to provide for procedures to ensure compliance with such developments. The parties
9 specifically agree to take such action as is necessary to amend this agreement in order to
10 implement the standards and requirements of HIPAA, the HIPAA regulations, the HITECH Act
11 and other applicable laws relating to the security or privacy of PHI. COUNTY may terminate
12 this Agreement upon thirty (30) days written notice in the event that CONTRACTOR does not
13 enter into an amendment providing assurances regarding the safeguarding of PHI that
14 COUNTY in its sole discretion, deems sufficient to satisfy the standards and requirements of
15 HIPAA, the HIPAA regulations and the HITECH Act.
16 R. No Third-Party Beneficiaries
17 Nothing express or implied in the terms and conditions of these provisions
18 is intended to confer, nor shall anything herein confer, upon any person other than COUNTY
19 or CONTRACTOR and their respective successors or assignees, any rights, remedies,
20 obligations or liabilities whatsoever.
21 S. Interpretation
22 The terms and conditions in these provisions shall be interpreted as
23 broadly as necessary to implement and comply with HIPAA, the HIPAA regulations and
24 applicable State laws. The parties agree that any ambiguity in the terms and conditions of
25 these provisions shall be resolved in favor of a meaning that complies and is consistent with
26 HIPAA and the HIPAA regulations.
27 T. Regulatory References
28 A reference in the terms and conditions of these provisions to a section in
-17-
1 the HIPAA regulations means the section as in effect or as amended.
2 U. Survival
3 The respective rights and obligations of CONTRACTOR as stated in this
4 Section shall survive the termination or expiration of this Agreement.
5 V. No Waiver of Obligations
6 No change, waiver or discharge of any liability or obligation hereunder on
7 any one or more occasions shall be deemed a waiver of performance of any continuing or
8 other obligation, or shall prohibit enforcement of any obligation on any other occasion.
9 16. NON-DISCRIMINATION
10 During the performance of this Agreement, CONTRACTOR shall not
11 unlawfully discriminate against any employee or applicant for employment, or recipient of
12 services, because of race, religious creed, color, national origin, ancestry, physical disability,
13 mental disability, medical condition, genetic information, marital status, sex, gender, gender
14 identity, gender expression, age, sexual orientation, military status or veteran status pursuant to
15 all applicable State of California and Federal statutes and regulation.
16 17. SEVERABILITY
17 The provisions of this Agreement are severable. The invalidity or
18 unenforceability of any one provision in the Agreement shall not affect the other provisions.
19 18. ENTIRE AGREEMENT: This Agreement constitutes the entire agreement
20 between the CONTRACTOR and COUNTY with respect to the subject matter hereof and
21 supersedes all previous Agreement negotiations, proposals, commitments, writings,
22 advertisements, publications, and understanding of any nature whatsoever unless expressly
23 included in this Agreement. In the event of any inconsistency in interpreting the documents which
24 constitute this Agreement, the inconsistency shall be resolved by giving precedence in the
25 following order of priority: (1) the text of this Agreement (excluding Exhibit "C'; the COLINTY'S
26 Request for Quotation/Proposal No. RFQ 18-013 and the CONTRACTOR'S Quote/Proposal in
27 response thereto); (2) the COUNTY'S Request for Quotation/Proposal No. 18-013; and (3) the
28 CONTRACTOR'S quotation/proposal made in response to COUNTY'S Request for
-18-
1 Quotation/Proposal No. 18-013.1
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1 IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the day and
2 year first hereinabove written.
3 CONTRACTOR COUNTY OF FRESNO
4 �
(Auth rized Signature) Sal Qu' er Chaiperson of the Board of
5 up 's of the County of Fresno
6 Kathy Hegstrom, President
Print Name &Title
� 7
5000 Airport Plaza Drive, Suite 150
8
Long Beach, CA 90815
9 Mailing Address ATTEST:
Bernice E. Seidel
10 Clerk of the Board of Supervisors
11 County of Fresno, State of California
12
CLNL
1 By.
3
Deputy
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16 FOR ACCOUNTING USE ONLY:
17 Fund: 0130
18 Org: 5244
Account: 7295
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-20-
1 EXHIBIT A
2
I. SCOPE OF WORK
3
A. Fully adjudicate claims received on a monthly basis received from authorized providers within
4
forty-five (45) business days after receipt of correctly submitted claims or invoices, and
5
supporting documentation (when applicable), at the rate specified by the County, and make
6
other required payments.
7
B. CONTRACTOR shall continuously provide sufficient staffing including production, supervisory
8
and management staff to ensure timely and efficient performance of the services herein.
9
C. Receive, maintain, collect, and account for funds.
10
D. Review all claims to ensure County responsibility is verified including but not limited to checking
11
against Medi-Cal eligibility lists and verifying physician efforts to collect payments. Ensure that
12
the County is the payor of last resort.
13
E. Apply industry standard procedures for claims review. Request supporting claims
14
documentation from authorized providers when appropriate. Deny all claims that do not meet
15
the conditions and requirements for claims submission, processing, and reimbursement.
16
F. Notify providers in writing of the reason for any denial of a Claim(s).
17
G. CONTRACTOR shall submit their procedures for claims review to the County within thirty (30)
18
calendar days of the start of the executed contract.
19
H. Receive, compile, preserve, and report information and data to the County on a monthly
20
schedule to be agreed upon between the County and the CONTRACTOR. Reports shall be
21
provided as a Microsoft Excel spreadsheet or format mutually agreed upon by all parties, and/or
22
shall be available to the County via a secure web-based reporting tool/portal. General types of
23
reports for all programs shall include, but not be limited to:
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1. Claims Detail Report and Claims Summary Report
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2. Claims Status Report and Claims Status Summary Report
26
3. Fund Reconciliation Report
27
4. Account Statement
28
5. Service Utilization Report
1 6. Recovery Account Status Report
2 7. Denial Report
3 8. Ad-hoc Reports
4 I. Implement HIPAA compliant encryption security measures for authorized providers to submit
5 electronic claims data; provide training to providers on those security measures, and ensure
6 those security measures are adhered to
7 J. Designate a primary and alternate contact persons dedicated to facilitating communication with
8 authorized providers submitting claims, County staff, and authorized patient representatives,
9 and ensure all parties have the relevant phone number and email address.
10 K. Retain and maintain all records relating to patient care unless Agreement is terminated in which
11 CONTRACTOR will forward all records to the appropriate vendor or return to COUNTY upon
12 COUNTY's instruction.
13 L. Review and pay claims based on the date services are provided; and in strict accordance with
14 Maddy Emergency Medical Services Fund requirements enumerated by the State of California
15 and COUNTY.
16 M. Authorized providers shall have up to one hundred twenty (120) days of the date of service to
17 submit claims for services; however, they cannot bill for services prior to ninety (90) days
18 following the date of service as they must be able to demonstrate, if audited, that they have
19 made three (3) attempts to collect from the patient and/or other insurance providers and have
20 been unsuccessful in that collection effort.
21 N. Pay claims up to the maximum amount an authorized provider may be paid, as specified by law.
22 At Final Payout, authorized providers are paid at a percentage of Resource Base Relative Value
23 Scale (RBRVS) determined by the County, or 50% of allowable charges, whichever is less. The
24 rate shall be based upon the total dollars available divided by the total value of all claims. The
25 maximum payment limits apply at Final Settlement.
26 O. If it is determined after March 31st, for each Period that continued payment of the established
27 RBRVS through June 30th, for each Period, will exceed available Funds, COUNTY may direct
28 CONTRACTOR to pay Claims up to the amount of remaining available Funds at the presently
1 established RBRVS, less estimated administrative costs for CONTRACTOR, COUNTY, and any
2 other Agreements in support of the EMSF Program; suspend payment of all remaining Claims
3 submitted through June 30th; or pay those suspended Claims in the following Fiscal Year at the
4 RBRVS established for that following Fiscal Year. COUNTY shall use best efforts to notify
5 CONTRACTOR sixty (60) days prior to March 31st if available finds will be exceeded to ensure
6 timely suspension of claims payment.
7 P. Final Payout Procedures
8 1. At Final Payout, if adjustments to reduce the RBRVS were made during the Fiscal Year,
9 funds shall be first used to pay those Physicians who received payment at an RBRVS
10 less than that paid to any Physicians at any other time during the Fiscal Year, up to the
11 maximum RBRVS paid during the year, . Any other remaining Funds shall then be
12 distributed as provided below.
13 a) Final Payout is defined as the final reimbursement of Physicians at the close
14 of a given fiscal year.
15 2. No later than July 31 st following each Period:
16 a) COUNTY shall perform a final reconciliation of Funds remaining in the EMSF
17 Trust Fund, CONTRACTOR's Account, and the Recovery Accounts for the
18 purpose of determining the amount to distribute to Physicians as Final Pay
19 after all other obligations provided through this Agreement are met.
20 b) CONTRACTOR shall report to COUNTY, the value of any pending Claims and
21 the date the claims are anticipated to be paid
22 c) COUNTY shall report to CONTRACTOR the Fund balance, if any, to be
23 distributed through Final Payout. CONTRACTOR shall invoice COUNTY for
24 this amount, which amount COUNTY shall pay, and CONTRACTOR shall
25 deposit in the Account. CONTRACTOR shall disburse such Funds, the
26 balance of all other monies in the Account and any other accounts maintained
27 for the purposes of the Agreement, and any earned interest, to Physicians in
28 the manner specified in the Agreement. Funds shall be distributed
1 proportionately, based on the dollar amount of Claims submitted and paid to
2 all physicians and surgeons who submitted qualifying claims during the year,
3 in accordance with Health and Safety Code Section 1797.98a(d).
4 d) As recovery funds are received, CONTRACTOR shall deposit any Recovery
5 Account balance into the Fund.
6 Q. Complete the Final Settlement process within six months following the end of the fiscal year if
7 funds remain in the Account, to distribute the balance of the funds proportionate to the claims
8 paid during the contract period.
9 R. Maintain a physician registration system acceptable to COUNTY, and only reimburse physicians
10 that are registered
11 1. The registration system shall include Conditions of Participation" (COPs) that registered
12 providers must agree to in order to participate in the EMS Program, and certain of these
13 COPs may require specific acceptance/agreement by the provider before moving on in
14 the registration process.
15 2. Conditions of Participation shall include, at minimum:
16 a. Services must be provided in a basic or comprehensive general acute care
17 hospital emergency department.
18 b. The physician or surgeon may not be an employee of the hospital
19 c. Reimbursement from the program is sought by the hospital or the hospital's
20 designee, as the billing and collection agent for the emergency physician and
21 surgeon, or an emergency physician group.
22 d. The physician may not utilize the program if the COUNTY has separately
23 established any other billing mechanism to permit the physician to bill the
24 COUNTY for his/her services.
25 S. Provide directly, or through a County-approved subcontract arrangement, third-party recovery
26 services to actively pursue reimbursement of claims paid from the Physician Services Account
27 (PSA) fund that are later determined to be eligible for Medi-Cal, other insurance or third-party
28 payment. If services are provided directly, CONTRACTOR shall be reimbursed twenty percent
1 (20%) of the recovered payments and refunds.
2 T. Recovery payments and refunds on claims shall be deposited into a recovery account.
3 U. CONTRACTOR agrees to provide the resources necessary to address any backlog claims
4 processing or an increased influx of claims within the time periods specified herein.
5 V. CONTRACTOR shall review Claims and may provide a medical review, as appropriate, in
6 accordance with its Operations Manual. CONTRACTOR shall keep a copy of its current
7 Operations Manual at its main facility which shall include CONTRACTOR's policies and
8 procedures relating to its operations, including, but not limited to the activities specified herein.
9 W. CONTRACTOR shall deny all Claims that do not meet the conditions and requirements of the
10 Agreement and/or state regulations for Claim submission, processing, and reimbursement.
11 X. CONTRACTOR shall use its best efforts to collect any monies paid, in any form, for
12 nonreimbursable services or for payment to any Physician or other entity not entitled under the
13 Agreement to such payment if the result of inaccurate or inappropriate processing by
14 CONTRACTOR. CONTRACTOR shall send a collection notice to the Physician or other entity. If
15 the initial notice is not successful, CONTRACTOR shall send a second notice. If the second
16 notice is unsuccessful CONTRACTOR shall send a third and final notice. Upon becoming aware
17 that such payments are uncollectible, CONTRACTOR shall submit to COUNTY a plan of
18 corrective action. Upon review by COUNTY, CONTRACTOR may be subject to disallowances
19 for said payments.
20 Y. CONTRACTOR shall make every effort to resolve appeals within forty five (45) days of receipt
21 through discussion with physician billing staff. For those appeals that cannot be resolved to the
22 satisfaction of the physician or group, CONTRACTOR shall establish a process by which
23 physicians or groups may escalate appeals to COUNTY no later than thirty (30) days following
24 notification of denial. If appeal is not received by COUNTY within this timeframe CONTRACTOR
25 decision shall be considered final.
26
27
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1 II. MINIMUM STANDARDS
2 CONTRACTOR shall ensure the following minimum standards are adhered to in the adjudication of
3 claims.
4 A. ELIGIBLE SERVICES
5 Funding Criteria - Reimbursements of physician claims must meet specific criteria, which are
6 outlined in the California Health and Safety Code and the Welfare & Institutions Code. The
7 eligibility requirements for the program are as follows:
8 1. Traffic Fines and Penalties - Emergency services within 48 hours
9 These funds allow for reimbursement for emergency care prior to stabilization. For the
10 purposes of reimbursement from this program, the point of stabilization is 48 hours of
11 continuous service to the patient from the point of emergency department contact or
12 receipt of transfer. This includes medical screening examinations required by law to
13 determine whether an emergency condition exists.
14 2. Emergency Medical Condition - Defined as a medical condition manifesting itself by
15 acute symptoms of sufficient severity, including severe pain, which in the absence of
16 immediate medical attention could reasonably be expected to result in any of the
17 following:
18 a) Placing the patient's health in serious jeopardy;
19 b) Serious impairment to bodily functions; or,
20 c) Serious dysfunction to any bodily organ or part.
21 3. Location of Service - Emergency medical services must have been provided by a
22 physician in a general acute care hospital which meets one of the following conditions:
23 a) The hospital has a permit to provide basic or comprehensive emergency
24 medical services; or,
25 b) The hospital has a permit for standby emergency services prior to July 1,
26 1991 and meets the criteria as a "small and rural hospital" as defined in
27 Section 124840 of the Health and Safety Code.
28
1 B. PATIENT ELIGIBILITY
2
Reimbursement under this claiming process shall be limited to services for which the physician,
3
following reasonable billing efforts has not received any payment from a patient or responsible party,
4
and the patient does not have health insurance for emergency services and care, cannot afford to pay
5
for those services, and for whom payment will not be made through any private coverage or by any
6
program funded in whole or in part by the federal government with the exception of claims submitted for
7
reimbursement through Section 1011 of the federal Medicare Prescription Drug, Improvement and
8
Modernization Act of 2003.
9
These procedures shall not be applied or interpreted so as to prevent a physician from seeking
10
or accepting payment from a patient or responsible third-party payor, or arranging a repayment
11
schedule for the costs of services rendered prior to receiving payment from this fund.
12
13 C. CLAIM ELIGIBILITY
14
15 Physicians must make reasonable efforts to bill for services provided. Claims are eligible for
16 reimbursement through this fund if all of the following conditions are met:
17 1. The physician has inquired if there is a responsible third-party source of payment.
18 2. The physician has billed the patient and, if identified, a responsible third party for
19 payment of services.
20 3. The physician has made reasonable efforts to collect payment (the physician's
21 records should maintain evidence of such effort). For purposes of the PSA,
22 reasonable efforts shall be defined as one of the following:
23 a. A period of not less than three (3) months has passed since the initial billing, and
24 there has been a minimum of three (3) billings by the physician (the three billing
25 requirement is waived if a billing is returned by postal authorities marked "no
26 known forwarding address" or "addressee unknown" and the physician made
27 reasonable efforts to discover a correct billing address); or
28 b. The physician has received actual notification from the patient or responsible third
party that no payment will be made for the services rendered by the physician.
1 4. The physician has not received reimbursement of any portion of the amount billed to
2 the patient. Deposits for services made by the patient or responsible party are
3 considered partial payments and result in the service not being eligible for
4 reimbursement under this program. Deposits for specific services will apply only
5 towards that specific service and will not affect other claims for different services
6 for that same patient on different dates.
7 5. Physicians must stop any current, and waive any future, collection efforts to obtain
8 reimbursement from the patient, upon receipt of funds from the PSA.
9 a. If a physician receiving payment under the program is later reimbursed by a patient
10 or responsible party, the physician shall notify the CONTRACTOR. CONTRACTOR
11 shall reduce the physician's future payment of claims from the account. In the event
12 there is not a subsequent submission of a claim for reimbursement within one year,
13 the physician shall reimburse the account in an amount equal to the amount
14 collected from the patient or third-party payer, but not more than the amount of
15 reimbursement received from the account; or, Notify CONTRACTOR of the
16 payment and, reimburse the account in an amount equal to the amount collected
17 from the patient or third-party payer, but not more than the amount of the
18 reimbursement received from the account for that patient's care.
19 b. In the event the physician receives payment from any source on a claim that has
20 been submitted to CONTRACTOR, but has not yet been reimbursed from the PSA,
21 the physician shall contact the CONTRACTOR and request that the claim be
22 withdrawn from the program.
23 6. If a pattern of incomplete, ineligible, or unsubstantiated claims is determined by
24 COUNTY and CONTRACTOR to be continuing, the Physician may be excluded
25 from submitting future requests for reimbursement.
26 7. Any refunds or penalties shall be paid to CONTRACTOR and deposited into the
27 account to fund future payments to physicians.
28
Exhibit B
Page 1 of 2
SELF-DEALING TRANSACTION DISCLOSURE FORM
In order to conduct business with the County of Fresno (hereinafter referred to as "County"),
members of a contractor's board of directors (hereinafter referred to as "County Contractor"), must
disclose any self-dealing transactions that they are a party to while providing goods, performing
services, or both for the County. A self-dealing transaction is defined below:
"A self-dealing transaction means a transaction to which the corporation is a party and in which one
or more of its directors has a material financial interest."
The definition above will be utilized for purposes of completing this disclosure form.
INSTRUCTIONS
(1) Enter board member's name,job title (if applicable), and date this disclosure is being made.
(2) Enter the board member's company/agency name and address.
(3) Describe in detail the nature of the self-dealing transaction that is being disclosed to the
County. At a minimum, include a description of the following:
a. The name of the agency/company with which the Corporation has the transaction;
and
b. The nature of the material financial interest in the Corporation's transaction that the
board member has.
(4) Describe in detail why the self-dealing transaction is appropriate based on applicable
provisions of the Corporations Code.
(5) Form must be signed by the board member that is involved in the self-dealing transaction
described in Sections (3) and (4).
Exhibit B
Page 2 of 2
(1)Company Board Member Information:
Name: Date:
Job Title:
(2)Company/Agency Name and Address:
(3) Disclosure(Please describe the nature of the self-dealing transaction you are a party to):
(4) Explain why this self-dealing transaction is consistent with the requirements of Corporations Code 5233(a):
(5)Authorized Signature
Signature: Date:
EXHIBIT C Exhibit
Page 1 of 64
COUNTY OF FRESNO
co
FR$5
REQUEST FOR QUOTATION
NUMBER: 18-013
FISCAL INTERMEDIARY FOR THE EMERGENCY
MEDICAL SERVICES FUND
Issue Date: October 13, 2017
Closing Date: NOVEMBER 15, 2017 AT 2:00 P.M.
All Questions and Quotations must be electronically submitted on the Bid Page on Public Purchase.
For assistance, contact Darren Howard at Phone (559) 600-7110.
BIDDER TO COMPLETE
Undersigned agrees to furnish the commodity or service stipulated in the attached response at the prices and terms stated in this RFQ.
Bid must be signed and dated by an authorized officer or employee.
Except as noted on individual items,the following will apply to all items in the Quotation Schedule:
• Acash discount of % days will apply.County does not accept terms less than 15 days.
COMPANY
ADDRESS
CITY STATE ZIP CODE
TELEPHONE NUMBER FACSIMILE NUMBER E-MAIL ADDRESS
SIGNATURE
PRINT NAME TITLE
Purchasing Use:DHst ORG/Requis ition:56208799/5621800305
Exhibit C
Page 2 of 64
TABLE OF CONTENTS
PAGE
KEYDATES .................................................................................................................... 3
OVERVIEW..................................................................................................................... 3
BID INSTRUCTIONS ......................................................................................................4
GENERAL REQUIREMENTS & CONDITIONS............................................................... 5
INSURANCE REQUIREMENTS ................................................................................... 11
PARTICIPATION........................................................................................................... 12
REFERENCE LIST........................................................................................................ 13
SCOPEOF WORK........................................................................................................ 14
COMPLY/NOT COMPLY............................................................................................... 15
QUOTATION SCHEDULE............................................................................................. 18
CHECKLIST ................................................................................................................. 19
EXHIBITS...................................................................................................................... 20
Exhibit C
Page 3 of 64
KEY DATES
RFQ Issue Date: October 13, 2017
Written Questions for RFQ Due: November 1, 2017 at 10:00 A.M.
Questions must be submitted on the Bid Page at Public Purchase.
RFQ Closing Date: November 15, 2017 at 2:00 P.M.
Quotations must be electronically submitted on the Bid Page.
OVERVIEW
The County of Fresno Department of Public Health (DPH) is seeking bids from qualified organizations to
provide Fiscal Intermediary(FI) Services to County Authorized providers for the County of Fresno Physicians
Services Account(PSA) also known as the Maddy Emergency Medical Services Fund. The primary goal of
this program is to provide accurate, timely, efficient, cost effective, and consistent claims processing and
management for FI services.
PSA is responsible for reimbursement of physicians providing medical screening, examination, and
evaluation of a patient in a hospital emergency department to determine if an emergency medical condition
exists and, if so, reimbursement of the care, treatment and/or surgery necessary to stabilize the patient. FI
Services for this program will process payment of claims for physicians for whom no payment has been
made from responsible parties.
Exhibit C
Page 4 of 64
BID INSTRUCTIONS
• Bidders must electronically submit bid package in pdf format, no later than the quotation closing date
and time as stated on the front of this document, to the Bid Page on Public Purchase. The County will
not be responsible for and will not accept late bids due to slow internet connection or incomplete
transmissions.
• Bids received after the closing time will NOT be considered.
• All quotations shall remain firm for 180 days.
• Interpretation: Should any discrepancies or omissions be found in the bid specifications or doubt as to
their meaning, the bidder shall notify the Buyer in writing at once. The County shall not be held
responsible for verbal interpretations. Questions regarding the bid must be received by Purchasing
stated within this document. All addenda issued shall be in writing, duly issued by Purchasing and
incorporated into the contract.
• ISSUING AGENT/AUTHORIZED CONTACT: This RFQ has been issued by County of Fresno,
Purchasing. Purchasing shall be the vendor's sole point of contact with regard to the RFQ, its
content, and all issues concerning it.
All communication regarding this RFQ shall be directed to an authorized representative of County
Purchasing. The specific buyer managing this RFQ is identified on the cover page, along with his or
her telephone number, and he or she should be the primary point of contact for discussions or
information pertaining to the RFQ. Contact with any other County representative, including elected
officials, for the purpose of discussing this RFQ, its content, or any other issue concerning it, is
prohibited unless authorized by Purchasing. Violation of this clause, by the vendor having
unauthorized contact (verbally or in writing) with such other County representatives, may constitute
grounds for rejection by Purchasing of the vendor's quotation.
The above stated restriction on vendor contact with County representatives shall apply until the
County has awarded a purchase order or contract to a vendor or vendors, except as follows. First, in
the event that a vendor initiates a formal protest against the RFQ, such vendor may contact the
appropriate individual, or individuals who are managing that protest as outlined in the County's
established protest procedures. All such contact must be in accordance with the sequence set forth
under the protest procedures. Second, in the event a public hearing is scheduled before the Board of
Supervisors to hear testimony prior to its approval of a purchase order or contract, any vendor may
address the Board.
• APPEALS: Appeals must be submitted in writing within seven (7)working days after notification of
proposed recommendations for award. A"Notice of Award" is not an indication of County's
acceptance of an offer made in response to this RFQ. Appeals shall be submitted to County of
Fresno Purchasing, 4525 E. Hamilton Avenue 2nd Floor, Fresno, California 93702-4599 and in Word
format to gcornuelle@co.fresno.ca.us. Appeals should address only areas regarding RFQ
contradictions, procurement errors, quotation rating discrepancies, legality of procurement context,
conflict of interest, and inappropriate or unfair competitive procurement grievance regarding the RFQ
process.
Purchasing will provide a written response to the complainant within seven (7) working days unless
the complainant is notified more time is required. If the appealing bidder is not satisfied with the
decision of Purchasing, he/she shall have the right to appeal to the County Administrative Office
within seven (7)working days after Purchasing's notification; if the appealing bidder is not satisfied
with CAO's decision, the final appeal is with the Board of Supervisors. Please contact Purchasing if
the appeal will be going to the Board of Supervisors.
Exhibit C
Page 5 of 64
GENERAL REQUIREMENTS & CONDITIONS
LOCAL VENDOR PREFERENCE AND DISABLED VETERAN BUSINESS ENTERPRISE BID
PREFERENCE: The Local Vendor Preference and Disabled Veteran Business Enterprise Preference do
not apply to this Request for Quotation.
DEFINITIONS: The terms Bidder, Proposer, Contractor and Vendor are all used interchangeably and refer
to that person, partnership, corporation, organization, agency, etc. which is offering the quotation and is
identified on page one of this Request For Quotation (RFQ).
INTERPRETATION OF RFQ: Vendors must make careful examination of the requirements, specifications
and conditions expressed in the RFQ and fully inform themselves as to the quality and character of services
required. If any person planning to submit a quotation finds discrepancies in or omissions from the RFQ or
has any doubt as to the true meaning or interpretation, correction thereof may be requested in writing from
Purchasing by November 1, 2017 at 10:00 A.M., cut-off.
Questions must be submitted on the Bid Page at Public Purchase or contact Darren Howard at(559) 600-
7110.
NOTE: Time constraints will prevent County from responding to questions submitted after the cut-off date.
Any change in the Request for Quotation will be made by written addendum issued by the County. The
County will not be responsible for any other explanations or interpretations.
AWARD: Award will be made to the vendor(s) offering the services, products, prices, delivery, equipment
and system deemed to be to the best advantage of the County. The County shall be the sole judge in
making such determination. Award Notices are tentative: Acceptance of an offer made in response to this
RFQ shall occur only upon execution of an agreement by both parties or issuance of a valid written Purchase
Order by Fresno County Purchasing.
RIGHT TO REJECT BIDS: The County reserves the right to reject any and all bids and to waive
informalities or irregularities in bids. Failure to respond to all questions or not to supply the requested
information could result in rejection of your quotation.
CODES AND REGULATIONS: All work and material to conform to all applicable Federal, State, local and
special district building codes, laws, ordinances, and regulations.
TAXES: The quoted amount must include all applicable taxes. If taxes are not specifically identified in the
quotation it will be assumed that they are included in the total quoted.
SALES TAX: Fresno County pays California State Sales Tax in the amount of 7.975% regardless of
vendor's place of doing business.
TAXES, PERMITS & FEES: The successful bidder shall pay for and include all federal, state and local taxes
direct or indirect upon all materials; pay all fees for, and obtain all necessary permits and licenses, unless
otherwise specified herein.
TAXES, CHARGES AND EXTRAS:
A) DO NOT include Federal Excise Tax. County is exempt under Registration No. 94-73-03401-K.
B) County is exempt from Federal Transportation Tax. Exemption certificate is not required where shipping
papers show consignee as County of Fresno.
C) Charges for transportation, containers, packing, etc. will not be paid unless specified in bid.
VENDOR ASSISTANCE: Successful bidder shall furnish, at no cost to the County, a representative to assist
County departments in determining their product requirements.
Exhibit C
Page 6 of 64
MINOR DEVIATIONS: The County reserves the right to negotiate minor deviations from the prescribed
terms, conditions and requirements with the selected vendor.
BIDDERS' LIABILITIES: County of Fresno will not be held liable for any cost incurred by vendors in
responding to the RFQ.
PRICE RESPONSIBILITY: The selected vendor will be required to assume full responsibility for all services
and activities offered in the quotation, whether or not they are provided directly. Further, the County of
Fresno will consider the selected vendor to be the sole point of contact with regard to contractual matters,
including payment of any and all charges resulting from the contract. The contractor may not subcontract or
transfer the contract, or any right or obligation arising out of the contract, without first having obtained the
express written consent of the County.
PRICES: Bidder agrees that prices quoted are for the contract period, and in the event of a price decline
such lower prices shall be extended to the County of Fresno. Prices shall be quoted F.O.B. destination.
CONFIDENTIALITY: Bidders shall not disclose information about the County's business or business
practices and safeguard confidential data which vendor staff may have access to in the course of system
implementation.
HIPAA: All services performed by vendor shall be in strict conformance with all applicable Federal, State
of California and/or local laws and regulations relating to confidentiality, including but not limited to,
California Civil Code, California Welfare and Institutions Code, Health and Safety Code, California Code of
Regulations, Code of Federal Regulations.
Vendor shall submit to County's monitoring of said compliance.
Vendor may be a business associate of County, as that term is defined in the "Privacy Rule" enacted by
the Health Insurance Portability and Accountability Act of 1996 (HIPAA). As a HIPAA Business Associate,
vendor may use or disclose protected health information ("PHI") to perform functions, activities or services
for or on behalf of County as specified by the County, provided that such use or disclosure shall not violate
HIPAA and its implementing regulations. The uses and disclosures if PHI may not be more expansive than
those applicable to County, as the "Covered Entity" under HIPAA's Privacy Rule, except as authorized for
management, administrative or legal responsibilities of the Business Associate.
Vendor shall not use or further disclose PHI other than as permitted or required by the County, or as
required by law without written notice to the County.
Vendor shall ensure that any agent, including any subcontractor, to which vendor provides PHI received
from, or created or received by the vendor on behalf of County, shall comply with the same restrictions and
conditions with respect to such information.
NEWS RELEASE: Vendors shall not issue any news releases or otherwise release information to any third
party about this RFQ or the vendor's quotation without prior written approval from the County of Fresno.
BACKGROUND REVIEW: The County reserves the right to conduct a background inquiry of each
proposer/bidder which may include collection of appropriate criminal history information, contractual and
business associations and practices, employment histories and reputation in the business community. By
submitting a quotation/bid to the County, the vendor consents to such an inquiry and agrees to make
available to the County such books and records the County deems necessary to conduct the inquiry.
ADDENDA: In the event that it becomes necessary to revise any part of this RFQ, addenda will be provided
to all agencies and organizations that receive the basic RFQ.
Exhibit C
Page 7 of 64
CONFLICT OF INTEREST: The County shall not contract with, and shall reject any bid or quotation
submitted by the persons or entities specified below, unless the Board of Supervisors finds that special
circumstances exist which justify the approval of such contract:
1. Employees of the County or public agencies for which the Board of Supervisors is the governing body.
2. Profit-making firms or businesses in which employees described in Subsection (1) serve as officers,
principals, partners or major shareholders.
3. Persons who, within the immediately preceding twelve (12) months, came within the provisions of
Subsection (1), and who were employees in positions of substantial responsibility in the area of service
to be performed by the contract, or participated in any way in developing the contract or its service
specifications.
4. Profit-making firms or businesses in which the former employees described in Subsection (3) serve as
officers, principals, partners or major shareholders.
5. No County employee whose position in the County enables him to influence the selection of a contractor
for this RFQ, or any competing RFQ, and no spouse or economic dependent of such employee, shall be
employees in any capacity by a bidder, or have any other direct or indirect financial interest in the
selection of a contractor.
INVOICING: All invoices are to be delivered in duplicate to The Department of Public Health, P.O. Box
11867, Fresno, CA 93775-1867. Reference shall be made to the purchase order/contract number and
equipment number if applicable on the invoice.
PAYMENT: County will make partial payments for all purchases made under the contract/purchase order
and accumulated during the month.
CONTRACT TERM: It is County's intent to contract with the successful bidder for a term of three (3)
years.
RENEWAL: Agreement may be renewed for a potential of two (2)one (1)year periods, based on the mutual
written consent of all parties.
QUANTITIES: Quantities shown in the bid schedule are approximate and the County guarantees no
minimum amount. The County reserves the right to increase or decrease quantities.
ORDERING: Orders will be placed as required by County of Fresno Department of Public Health.
TERMINATION: The County reserves the right to terminate any resulting contract upon written notice.
INDEPENDENT CONTRACTOR: In performance of the work, duties, and obligations assumed by
Contractor under any ensuing Agreement, it is mutually understood and agreed that CONTRACTOR,
including any and all of Contractor's officers, agents, and employees will at all times be acting and
performing as an independent contractor, and shall act in an independent capacity and not as an officer,
agent, servant, employee,joint venturer, partner, or associate of the COUNTY. Furthermore, County shall
have no right to control or supervise or direct the manner or method by which Contractor shall perform its
work and function. However, County shall retain the right to administer this Agreement so as to verify that
Contractor is performing its obligations in accordance with the terms and conditions thereof. Contractor and
County shall comply with all applicable provisions of law and the rules and regulations, if any, of
governmental authorities having jurisdiction over matters the subject thereof.
Because of its status as an independent contractor, Contractor shall have absolutely no right to employment
rights and benefits available to County employees. Contractor shall be solely liable and responsible for
providing to, or on behalf of, its employees all legally-required employee benefits. In addition, Contractor
shall be solely responsible and save County harmless from all matters relating to payment of Contractor's
employees, including compliance with Social Security, withholding, and all other regulations governing such
matters. It is acknowledged that during the term of the Agreement, Contractor may be providing services to
others unrelated to the County or to the Agreement.
Exhibit C
Page 8 of 64
SELF-DEALING TRANSACTION DISCLOSURE: Contractor agrees that when operating as a corporation
(a for-profit or non-profit corporation), or if during the term of the agreement the Contractor changes its status
to operate as a corporation, members of the Contractor's Board of Directors shall disclose any self-dealing
transactions that they are a party to while Contractor is providing goods or performing services under the
agreement with the County. A self-dealing transaction shall mean a transaction to which the Contractor is a
party and in which one or more of its directors has a material financial interest. Members of the Board of
Directors shall disclose any self-dealing transactions that they are a party to by completing and signing a
Fresno County Self-Dealing Transaction Disclosure Form and submitting it to the County prior to
commencing with the self-dealing transaction or immediately thereafter.
HOLD HARMLESS CLAUSE: Contractor agrees to indemnify, save, hold harmless and at County's request,
defend the County, its officers, agents and employees, from any and all costs and expenses, damages,
liabilities, claims and losses occurring or resulting to County in connection with the performance, or failure to
perform, by Contractor, its officers, agents or employees under this Agreement and from any and all costs
and expenses, damages, liabilities, claims and losses occurring or resulting to any person, firm or
corporation who may be injured or damaged by the performance, or failure to perform, of Contractor, its
officers, agents or employees under this Agreement.
STANDARD OF PERFORMANCE: All work shall be performed in a good and workmanlike manner.
SAFEGUARDS: The contractor shall provide safeguards, in conformity with all local codes and ordinances
as may be required.
DISPUTE RESOLUTION: The ensuing contract shall be governed by the laws of the state of California.
Any claim which cannot be amicably settled without court action will be litigated in the U.S. District Court for
the Eastern District of California in Fresno, CA or in a state court for Fresno County.
DEFAULT: In case of default by the selected bidder, the County may procure the services from another
source and may recover the loss occasioned thereby from any unpaid balance due the selected bidder, or by
any other legal means available to the County.
Regardless of F.O.B. point, vendor agrees to bear all risks of loss, injury or destruction to goods and
materials ordered herein which occur prior to delivery and such loss, injury or destruction shall not release
vendor from any obligation hereunder
ASSIGNMENTS: The ensuing proposed contract will provide that the vendor may not assign any payment
or portions of payments without prior written consent of the County of Fresno.
ASSURANCES: Any contract awarded under this RFQ must be carried out in full compliance with the Civil
Rights Act of 1964, the Americans With Disabilities Act of 1990, their subsequent amendments, and any and
all other laws protecting the rights of individuals and agencies. The County of Fresno has a zero tolerance
for discrimination, implied or expressed, and wants to ensure that policy continues under this RFQ. The
contractor must also guarantee that services, or workmanship, provided will be performed in compliance with
all applicable local, state, or federal laws and regulations pertinent to the types of services, or project, of the
nature required under this RFQ. In addition, the contractor may be required to provide evidence
substantiating that their employees have the necessary skills and training to perform the required services or
work.
OBLIGATIONS OF CONTRACTOR: Contractor warrants on behalf of itself and all subcontractors
engaged for the performance of the ensuing contract that only persons authorized to work in the United
States pursuant to the Immigration Reform and Control Act of 1986 and other applicable laws shall be
employed in the performance of the work hereunder.
TIE BIDS: With all other factors being equal, the contract shall be awarded to the Fresno County vendor
or, if neither or both are Fresno County vendors, the tied vendors will be granted the opportunity to submit
new bids or the entire bid may be rejected and re-bid. If the General Requirements of the RFQ state that
they are applicable, the provisions of the Fresno County Local Vendor Preference shall take priority over
this paragraph.
Exhibit C
Page 9 of 64
DATA SECURITY: Individuals and/or agencies that enter into a contractual relationship with the County for
the purpose of providing services must employ adequate controls and data security measures, both internally
and externally to ensure and protect the confidential information and/or data provided to contractor by the
County, preventing the potential loss, misappropriation or inadvertent access, viewing, use or disclosure of
County data including sensitive or personal client information; abuse of County resources; and/or disruption
to County operations.
Individuals and/or agencies may not connect to or use County networks/systems via personally owned
mobile, wireless or handheld devices unless authorized by County for telecommuting purposes and provide a
secure connection; up to date virus protection and mobile devices must have the remote wipe feature
enabled. Computers or computer peripherals including mobile storage devices may not be used (County or
Contractor device)or brought in for use into the County's system(s)without prior authorization from County's
Chief Information Officer and/or designee(s).
No storage of County's private, confidential or sensitive data on any hard-disk drive, portable storage device
or remote storage installation unless encrypted according to advance encryption standards (AES of 128 bit
or higher).
The County will immediately be notified of any violations, breaches or potential breaches of security related
to County's confidential information, data and/or data processing equipment which stores or processes
County data, internally or externally.
County shall provide oversight to Contractor's response to all incidents arising from a possible breach of
security related to County's confidential client information. Contractor will be responsible to issue any
notification to affected individuals as required by law or as deemed necessary by County in its sole
discretion. Contractor will be responsible for all costs incurred as a result of providing the required
notification.
AUDITS AND RETENTION: The Contractor shall maintain in good and legible condition all books,
documents, papers, data files and other records related to its performance under this contract. Such records
shall be complete and available to Fresno County, the State of California, the federal government or their
duly authorized representatives for the purpose of audit, examination, or copying during the term of the
contract and for a period of at least three (3) years following the County's final payment under the contract or
until conclusion of any pending matter(e.g., litigation or audit), whichever is later. Such records must be
retained in the manner described above until all pending matters are closed.
EPAYMENT OPTION: The County of Fresno provides an Epay Program which involves payment of invoices
by a secure Visa account number assigned to the supplier after award of contract. Notification of payments
and required invoice information are issued to the supplier's designated Accounts Receivable contact by e-
mail remittance advice at time of payment. To learn more about the benefits of an Epay Program, how it
works, and obtain answers to frequently asked questions, click or copy and paste the following URL into your
browser: www.bankofamerica.com/er)avablesvendors or call Fresno County Accounts Payable, 559-600-
3609.
Exhibit C
Page 10 of 64
BIDDER TO COMPLETE:
SUBCONTRACTORS:
List all subcontractors that would perform work in excess of one/half of one percent of the total amount of
your bid, and state general type of work such subcontractor would be performing. The primary contractor is
not relieved of any responsibility by virtue of using a subcontractor:
Exhibit C
Page 11 of 64
INSURANCE REQUIREMENTS
INSURANCE: Without limiting the COUNTY's right to obtain indemnification from CONTRACTOR or any
third parties, CONTRACTOR, at its sole expense, shall maintain in full force and effect, the following
insurance policies or a program of self-insurance, including but not limited to, an insurance pooling
arrangement or Joint Powers Agreement (JPA)throughout the term of the Agreement:
A. Commercial General Liabilitv: Commercial General Liability Insurance with limits of not less than One
Million Dollars ($1,000,000) per occurrence and an annual aggregate of Two Million Dollars
($2,000,000). This policy shall be issued on a per occurrence basis. COUNTY may require specific
coverages including completed operations, products liability, contractual liability, Explosion-Col lapse-
Underground, fire legal liability or any other liability insurance deemed necessary because of the nature
of this contract.
B. Automobile Liability: Comprehensive Automobile Liability Insurance with limits for bodily injury of not
less than Two Hundred Fifty Thousand Dollars ($250,000.00) per person, Five Hundred Thousand
Dollars ($500,000.00) per accident and for property damages of not less than Fifty Thousand Dollars
($50,000.00), or such coverage with a combined single limit of Five Hundred Thousand Dollars
($500,000.00). Coverage should include owned and non-owned vehicles used in connection with this
Agreement.
C. Professional Liability: If CONTRACTOR employs licensed professional staff, (e.g., Ph.D., R.N.,
L.C.S.W., M.F.C.C.) in providing services, Professional Liability Insurance with limits of not less than One
Million Dollars ($1,000,000.00) per occurrence, Three Million Dollars ($3,000,000.00)annual aggregate.
This coverage shall be issued on a per claim basis. Contractor agrees that it shall maintain, at its sole
expense, in full force and effect for a period of three years following the termination of this Agreement,
one or more policies of professional liability insurance with limits of coverage as specified herein.
D. Worker's Compensation: A policy of Worker's Compensation insurance as may be required by the
California Labor Code.
CONTRACTOR shall obtain endorsements to the Commercial General Liability insurance naming the County
of Fresno, its officers, agents, and employees, individually and collectively, as additional insured, but only
insofar as the operations under this Agreement are concerned. Such coverage for additional insured shall
apply as primary insurance and any other insurance, or self-insurance, maintained by COUNTY, its officers,
agents and employees shall be excess only and not contributing with insurance provided under
CONTRACTOR's policies herein. This insurance shall not be cancelled or changed without a minimum of
thirty(30) days advance written notice given to COUNTY.
Within thirty(30)days from the date CONTRACTOR executes this Agreement, CONTRACTOR shall provide
certificates of insurance and endorsement as stated above for all of the foregoing policies, as required
herein, to the County of Fresno, EMS Director, P.O. Box 11867, Fresno, CA 93775-1867, stating that
such insurance coverage have been obtained and are in full force; that the County of Fresno, its officers,
agents and employees will not be responsible for any premiums on the policies; that such Commercial
General Liability insurance names the County of Fresno, its officers, agents and employees, individually and
collectively, as additional insured, but only insofar as the operations under this Agreement are concerned;
that such coverage for additional insured shall apply as primary insurance and any other insurance, or
self-insurance, maintained by COUNTY, its officers, agents and employees, shall be excess only and not
contributing with insurance provided under CONTRACTOR's policies herein; and that this insurance shall not
be cancelled or changed without a minimum of thirty(30) days advance, written notice given to COUNTY.
In the event CONTRACTOR fails to keep in effect at all times insurance coverage as herein provided, the
COUNTY may, in addition to other remedies it may have, suspend or terminate this Agreement upon the
occurrence of such event.
All policies shall be with admitted insurers licensed to do business in the State of California. Insurance
purchased shall be purchased from companies possessing a current A.M. Best, Inc. rating of A FSC VII or
better.
Exhibit C
Page 12 of 64
BIDDER TO COMPLETE THE FOLLOWING:
PARTICIPATION
The County of Fresno is a member of the Central Valley Purchasing Group. This group consists of Fresno,
Kern, Kings, and Tulare Counties and all governmental, tax supported agencies within these counties.
Whenever possible, these and other tax supported agencies co-op (piggyback) on contracts put in place by
one of the other agencies.
Any agency choosing to avail itself of this opportunity, will make purchases in their own name, make
payment directly to the contractor, be liable to the contractor and vice versa, per the terms of the original
contract, all the while holding the County of Fresno harmless. If awarded this contract, please indicate
whether you would extend the same terms and conditions to all tax supported agencies within this group as
you are proposing to extend to Fresno County.
Yes, we will extend contract terms and conditions to all qualified agencies within the Central Valley
Purchasing Group and other tax supported agencies.
FE71No, we will not extend contract terms to any agency other than the County of Fresno.
(Authorized Signature)
Title
Exhibit C
Page 13 of 64
VENDOR MUST COMPLETE AND RETURN WITH REQUEST FOR QUOTATION.
Firm:
REFERENCE LIST
Provide a list of at least five (5) customers for whom you have recently provided similar
products/services. Be sure to include all requested information.
Reference Name: Contact:
Address:
City: State: Zip:
Phone No.: ( ) Date:
Service Provided:
Reference Name: Contact:
Address:
City: State: Zip:
Phone No.: ( ) Date:
Service Provided:
Reference Name: Contact:
Address:
City: State: Zip:
Phone No.: ( ) Date:
Service Provided:
Reference Name: Contact:
Address:
City: State: Zip:
Phone No.: ( ) Date:
Service Provided:
Reference Name: Contact:
Address:
City: State: Zip:
Phone No.: ( ) Date:
Service Provided:
Failure to provide a list of at least five (5) customers may be cause for rejection of this RFQ.
Exhibit C
Page 14 of 64
SCOPE OF WORK
The County of Fresno Department of Public Health (DPH) is seeking proposals from qualified organizations
to provide Fiscal Intermediary(FI) Services to County Authorized providers for the County of Fresno
Physicians Services Account(PSA) also known as the Maddy Emergency Medical Services Fund. The
primary goal of this program is to provide accurate, timely, efficient, cost effective, and consistent claims
processing and management for FI services.
PSA is responsible for reimbursement of physicians providing medical screening, examination, and
evaluation of a patient in a hospital emergency department to determine if an emergency medical condition
exists and, if so, reimbursement of the care, treatment and/or surgery necessary to stabilize the patient. FI
Services for this program will process payment of claims for physicians for whom no payment has been
made from responsible parties.
The current DPH policies and procedures pertaining to this program are included in Exhibit A. These policies
will be revised in consultation with the selected bidder to reflect new practices. Statutory references for the
Maddy Emergency Medical Services Fund are included in Exhibit B.
The approximations described in the table below are based on data at the time of release of this
solicitation, and will vary based on patient need. This information is provided for a twelve (12)
month period and for general information only; it does not constitute any commitment by the
County, nor does it guarantee any amount of dollars to be managed, number of providers, or number of
claims to be processed. Additionally, DPH currently has a backlog of claims similar to the amount described
in the table below. Processing of these claims is ongoing. DPH makes no commitment to the number of
claims that will be outstanding at the start of the eventual agreement for services.
Approximate Number Approximate Number Approximate Claim
of Providers of Claims Processed Payment
5 15,000 $500,000
The following pages state the specifications and requirements for the services covered under this Request
for Quotation. Bidders are instructed to indicate their compliance or non-compliance with specifications.
Compliance is to be noted by initialing the "Agree" box to the left of the specification. Non-compliance is to be
indicated by initialing the "Disagree" box to the left of the specification. Exceptions may be explained on a
separate page entitled "EXCEPTIONS". Each exception must appropriately reference the specification by
Item Number. The bidder's response to County specifications must be submitted as part of his/her quotation.
Exhibit C
Page 15 of 64
COMPLY/NOT COMPLY
Compliance and understanding of the specification is to be noted by marking "COMPLY" on the
line provided to the right of the specification. Non-compliance is to be indicated by marking
"NOT COMPLY" on the line. All non-compliant items must be accompanied by a detailed
statement explaining why they fail to meet the stated specification or requirement.
BIDDER TO COMPLETE THE FOLLOWING: COMPLY/
NOT COMPLY
1. Fully adjudicate claims received from authorized providers within forty-five (45)
business days after receipt of correctly submitted claims or invoices, and
supporting documentation (when applicable), at the rate specified by the County,
and make other required payments
2. Receive, maintain, collect, and account for funds.
3. Review all claims to ensure County responsibility is verified. Ensure that the
County is the payor of last resort.
4. Apply industry standard procedures for claims review. Request supporting claims
documentation from authorized providers when appropriate. Deny all claims that do
not meet the conditions and requirements for claims submission, processing, and
reimbursement.
5. The selected bidder shall submit their procedures for claims review to the County
within thirty(30) calendar days of the start of the executed contract.
6. Receive, compile, preserve, and report information and data to the County on a
schedule to be agreed upon between the County and the selected bidder. Reports
shall be provided as a Microsoft Excel spreadsheet in a format mutually agreed
upon by all parties, and/or shall be available to the County via a secure web-based
reporting tool/portal. General types of reports for all programs shall include, but not
be limited to:
a. Claims Detail Report and Claims Summary Report
b. Claims Status Report and Claims Status Summary Report
C. Fund Reconciliation Report
d. Account Statement
e. Service Utilization Report
f. Recovery Account Status Report
g. Denial Report
h. Ad-hoc Reports
7. Use a Health Insurance Portability and Accountability Act (HIPAA) compliant
automated claims system, and adhere to all Protected Health Information (PHI)
and Personal Identifiable Information (PII) regulations.
8. Implement encryption security measures for authorized providers to submit
electronic claims data; provide training to providers on those security measures,
and ensure those security measures are adhered to.
Exhibit C
Page 16 of 64
BIDDER TO COMPLETE THE FOLLOWING: COMPLY/
NOT COMPLY
9. Designate a primary and alternate contact persons dedicated to facilitating
communication with authorized providers submitting claims, County staff, and
authorized patient representatives, and ensure all parties have the relevant phone
number and email address.
10. Retain and maintain all records relating to patient care for a minimum of seven (7)
years.
11. Review and pay claims based on the date services are provided; and in
accordance with the specific funding source requirements, i.e., claims must be for
emergency services and/or care provided by a physician in a hospital emergency
room setting, and services rendered are within the appropriate time limits.
12. Authorized providers shall have up to four(4) months of the date of service quarter
ending date to submit claims for services; however, they cannot bill for services
prior to ninety(90) days following the date of service as they must be able to
demonstrate, if audited, that they have made three (3) attempts to collect from the
patient and have been unsuccessful in that collection effort.
13. Pay claims up to the maximum amount an authorized provider may be paid, as
specified by law. Authorized providers are currently paid at a percentage of
Resource Base Relative Value Scale (RBRVS)determined by the County, or 50%
of allowable charges, whichever is less. The maximum payment limits apply at
Final Settlement.
14. Request additional funds if the amount of claims received exceeds the amount of
funds initially made available.
15. Conduct the Final Settlement process within sixty(60) days following the end of the
contract year if funds remain in the Account, to distribute the balance of the funds
proportionate to the claims paid during the contract period.
16. Maintain a physician registration system in accordance with county policies, and
only reimburse physicians that are registered. The PSA Program will also provide
"Conditions of Participation" (COPS)that registered providers must agree to in
order to participate in the EMS Program, and certain of these COPs may require
specific acceptance/agreement by the provider before moving on in the registration
process.
17. Provide directly, or through a County-approved subcontract arrangement, third-
party recovery services to actively pursue reimbursement of claims paid from the
PSA fund that are later determined to be eligible for Medi-Cal, other insurance or
third-party payment.
Exhibit C
Page 17 of 64
BIDDER TO COMPLETE THE FOLLOWING: COMPLY/
NOT COMPLY
18. Organization possesses a minimum of five (5) years of experience and expertise
performing services for a California County similar in complexity and scope to the
requested services.
19. Organization agrees to entertain, and accept if feasible, proposals by the County to
add services similar in complexity and scope to the eventual agreement in the
future.
Exhibit C
Page 18 of 64
QUOTATION SCHEDULE
Propose your most competitive Average Cost per Claim for the contract period stated below based on the
equation provided. If awarded a contract, proposed rates will be finalized during contract negotiations.
A claim is defined as any request for payment of a medical service that the FI has to adjudicate (whether it is
approved, denied, incomplete, etc.). The process for one claim includes all administrative and customer
service transactions to process the entire claim, including review, investigation, adjustment (if necessary),
and remittance or denial of the claim. The proposed rate(s) must include all labor, materials, equipment,
insurance coverage, permits, licenses, preparation of all faxed and/or mailed/delivered reports, and all other
fees to provide the services specified in this solicitation; and include the rationale and methodology to justify
the proposed rate(s).
Approximate number of claims processed over 12 month period: 15,000
Total Negotiated Rate: $ (if proposed)
Total Fee-for-Service: $ (if proposed, include all costs you are proposing on a fee-for
service basis. Multiply your per claim rate by the estimated 15,000 claims per year)
Total Other Cost: $ (if proposed)
Please explain "Other"
Average Cost per Claim*: $
*Average Cost per Claim = the Total of the values entered for Total Negotiated Rate, Total Fee-for-Service,
and Total Other divided by 15,000.
Exhibit C
Page 19 of 64
CHECK LIST
This Checklist is provided to assist the vendors in the preparation of their bid response. Included in this list,
are important requirements and is the responsibility of the bidder to submit with the bid package in order to
make the bid compliant. Because this checklist is just a guideline, the bidder must read and comply with the
bid in its entirety.
Check off each of the following:
1. The Request for Quotation (RFQ) has been signed and completed.
2. Addenda, if any, have been signed and included in the bid package.
3. The completed Reference List as provided with this RFQ.
4. The Quotation Schedule as provided with this RFQ has been completed, price reviewed for
accuracy and any corrections initialed.
5. Indicate all of bidder exceptions to the County's requirements, conditions and specifications
as stated within this RFQ.
6. The Participation page as provided within this RFQ has been signed and included
7. Bidder to Complete page as provided with this RFQ.
8. Return checklist with RFQ response.
9. Completed RFQ in pdf format, electronically submitted to the Bid Page on Public
Purchase.
Exhibit C
Page 20 of 64
EXHIBITS
A. Fresno County Physician Services Account Reimbursement Claim Procedures
B. California Legislative Information
Exhibit C
Page 21 of 64
FRESNO COUNTY
PHYSICIAN SERVICES ACCOUNT
REIMBURSEMENT CLAIM PROCEDURES
Department of Public Health
December 7, 2006
Revised August 28, 2013
Exhibit C
Page 22 of 64
TABLE OF CONTENTS
1. POLICY..................................................................................................................................3
II. INTRODUCTION..................................................................................................................4
A. FUNDING................................................................................................................4
B. PHYSICIAN ELIGIBILITY....................................................................................4
C. SERVICES ELIGIBLE FOR REIMBURSEMENT................................................5
1. FUNDING CRITERIA..................................................................................6
2. EMERGENCY MEDICAL CONDITION....................................................6
3. LOCATION OF SERVICE...........................................................................6
D. PATIENT ELIGIBILITY.........................................................................................6
E. CLAIM ELIGIBILITY ............................................................................................7
III. CLAIMS PROCESS...............................................................................................................8
A. FUNDING SOURCE...............................................................................................8
B. FEE SCHEDULE.....................................................................................................8
C. CLAIMS SUBMISSION..........................................................................................8
D. CLAIM SUBMISSION PERIOD............................................................................8
E. MEDICALLY INDIGENT CARE REPORTING SYSTEM(MICRS)INCIDENT/
SERVICEFORM.....................................................................................................8
F. SUSPENDED CLAIMS.........................................................................................I 1
G. POTENTIAL DUPLICATE CLAIMS...................................................................I 1
H. WITHDRAWING CLAIMS..................................................................................I I
I. MODIFICATION OF CLAIMS ............................................................................12
IV. COUNTY LIABILITY/PAYMENT....................................................................................12
A. AVAILABILITY OF MONIES IN COUNTY PHYSICIAN SERVICES
ACCOUNT............................................................................................................12
B. PAYMENT SCHEDULE.......................................................................................12
C. REMITTANCE INFORMATION.........................................................................12
D. PHYSICIAN COLLECTION EFFORTS AND REFUNDS..................................12
E. RECORDS/AUDIT/ADJUSTMENT.....................................................................13
F. DISPUTE RESOLUTION.....................................................................................14
ATTACHMENT A—APPLICATION FOR PROVIDER STATUS FOR PHYSICIAN SERVICES
ACCOUNT, UNCOMPENSATED CARE PROGRAM
ATTACHMENT B—PHYSICIAN PERSONAL DATA FORM
ATTACHMENT C—MICRS INCIDENT/SERVICE FORM
ATTACHMENT D—MICRS CONTROL SHEET
ATTACHMENT E—MICRS INCIDENT/SERVICE FORM—REFERENCE CODES
ATTACHMENT F—SUSPENDED ITEMS REPORT
ATTACHMENT G—POTENTIAL DUPLICATE CLAIMS REPORT
ATTACHMENT H—WITHDRAW REPORT
ATTACHMENT I—MICRS INCIDENT/SERVICE SUPPLEMENTAL CLAIM FORM
Exhibit C
Page 23 of 64
DEPARTMENT OF PUBLIC HEALTH
POLICIES AND PROCEDURES
Manual: Emergency Medical Services
Administrative Policies and Procedures PSA 001
Subject: Physician Services Account (PSA)—Reimbursement Claim Page: 3 of 15
Procedures
References: Health & Safety Code, Sections 1797.70, 1797.72, 1797.98, 124840 Effective:
Welfare & Institutions Code, Sections 16953
3/1/90
I. POLICY
Physicians shall be compensated for a portion of uncompensated care losses for services under the
Fresno County Physician Services Account (PSA). Compensation shall only be for eligible medical
services and shall be contingent upon the availability of funds specified in the California Health and
Safety Code and Welfare & Institutions Code and the physician's compliance with established claim
procedures. This claiming process shall be used for medical services provided on or after July 1, 1991.
This process shall be periodically audited and revised as needed.
The claims process outlined herein shall be used for physician services for emergency medical
conditions prior to stabilization, as defined in Sections 1797.70 and 1797.72 of Division 2.5 of the
California Health and Safety Code and Section 16953 of Division 9 of the California Welfare and
Institutions Code. This claiming process may be utilized contingent upon the availability of funds
defined in Section 16953 of the Welfare and Institutions Code.
Authority for the establishment of this claiming process is found in Section 1797.98 of the California
Health and Safety Code, effective January 1, 1988.
APPROVED BY: Revised:
IAugust 28,2013
Exhibit C
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SUBJECT: Physicians SerVices Account(PSA)—Reimbursement Claim Procedures—August 28,2013
PSA 001
II. INTRODUCTION
The provisions that follow define the claim procedures for submission to the County of Fresno for
physician claims for unpaid medical services. Services are limited to those that have been rendered in
Fresno County Reimbursement is contingent upon the availability of funds.
A. Funding
The County of Fresno PSA receives funding from traffic fines and penalties per Health and Safety
Code 1797.98 (1987)aka the"Maddy Emergency Medical Services (EMS) Fund".
These funds are deposited into the Fresno County PSA and distributed to eligible physicians in
accordance with established claim procedures.
B. Physician Eligibility
Physicians and surgeons are eligible to receive payment for allowable services provided by, or in
conjunction with, a properly credentialed nurse practitioner(NP)or physician's assistant(PA), for
care rendered under the direct supervision of a physician and surgeon who is present in the facility
where the patient is being treated, and who is available for immediate consultation.*
The physician may, individually or as a group, submit a claim for emergency medical services. Prior
to or concurrent with initial claims submission, the physician or physician group must apply for
provider status utilizing the Application for Provider Status for Physician Services Account,
Uncompensated Care Program(Attachment A) and complete a Physician Personal Data Form
(Attachment B). Only services provided to Fresno County residents at Fresno County hospitals are
eligible for reimbursement.
A physician may not utilize this billing process if the County has separately established any other
billing mechanism to permit the physician to bill the County for his/her services. An emergency
physician and surgeon, or an emergency physician group, with a gross billings arrangement with a
hospital shall be entitled to receive reimbursement from the PSA for services provided in that
hospital, if all of the following conditions are met:
1. The services are provided in a basic or comprehensive general acute care hospital emergency
department.
2. The physician and surgeon is not an employee of the hospital.
3. Reimbursement from the PSA is sought by the hospital or the hospital's designee, as the
billing and collection agent for the emergency physician and surgeon, or an emergency
physician group.
* These claims must be substantiated by a medical record and must be reviewed and countersigned by the supervising
physician and surgeon in accordance with regulations established for the supervision of NPs and PAs in California.
Exhibit C
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SUBJECT: Physician Services Account(PSA)—Reimbursement Claim Procedures—August 28,2013
PSA 001
4. All provisions of the billing/collection requirements are satisfied, except that payment to the
emergency physician and surgeon, or an emergency physician group, by a hospital pursuant
to a gross billings arrangement shall not be interpreted to mean that payment for a patient has
been made by a responsible third party.
For the purposes of this procedure, a"gross billings arrangement" is an arrangement whereby
a hospital serves as the billing and collection agent for the emergency physician and surgeon,
or an emergency physician group, and pays the emergency physician and surgeon, or an
emergency physician group, a percentage of the emergency physician and surgeon's or
group's gross billings for all patients. This includes physicians who staff emergency
departments or are providing"on-call" specialty services to the emergency department. The
physician may not provide these services as an employee of a county hospital.
Each physician must apply for PSA provider status and complete a Physician Personal Data Form.
Once a physician has applied for and received provider status, reapplication is not necessary unless
information on the application becomes outdated or has changed. This provider status allows for
billing to the PSA and establishes an account for that physician. The application must include the
physician's California license number and National Provider Identification(NPI)number. A current
IRS Form W-9"Request for Taxpayer Identification Number and Certification"and IRS Form 590
"Withholding Exemption Certification"must also be submitted with the application. The physician
must provide updated W-9 and 590 forms at the County's request thereafter. The physician's license
number will be utilized as the physician provider number for the PSA. Physician groups may also
apply for group provider status. The"Application for Provider Status"is included as Attachment A;
the "Physician Personal Data form" is included as Attachment B.
NOTE: The physician should apply prior to, or in conjunction with, the initial submission of
claims. Failure to apply for provider status may result in denial of claims.
Hospitals may bill on behalf of an emergency physician or emergency physician group consistent
with the provisions of this procedure.
Each physician must individually submit an application(even if part of a group), unless that
physician has contracted with a group or hospital to bill on their behalf. If such an agreement is in
effect, the group or hospital may apply on the physician's behalf. The group or hospital must
provide the Fresno County Department of Public Health's Business Office a copy of the agreement,
which specifically delegates authority from the physician to the group or hospital to bill on the
physician's behalf.
C. Services Eligible for Reimbursement
The funding source of the PSA requires specific criteria to be satisfied before payment for services
can be authorized. Distributions of funds from the PSA are authorized by the County of Fresno,
Department of Public Health, Business Office known herein as"DPH Business Office".
Exhibit C
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SUBJECT: Physician Services Account(PSA)—Reimbursement Claim Procedures -August 28, 2013
7 PSA 001
1. Funding Criteria- Reimbursements of physician claims must meet specific criteria, which are
outlined in the California Health and Safety Code and the Welfare& Institutions Code. The
eligibility requirements for"Maddy" (EMS) funds are as follows:
• Traffic Fines and Penalties—Emergency services within 48 hours
These funds allow for reimbursement for emergency care prior to stabilization. For the
purposes of reimbursement from this program, the point of stabilization is 48 hours of
continuous service to the patient from the point of emergency department contact or
receipt of transfer. This includes medical screening examinations required by law to
determine whether an emergency condition exists.
2. Emergency Medical Condition- Defined as a medical condition manifesting itself by acute
symptoms of sufficient severity, including severe pain, which in the absence of immediate
medical attention could reasonably be expected to result in any of the following:
• Placing the patient's health in serious jeopardy;
• Serious impairment to bodily functions; or,
• Serious dysfunction to any bodily organ or part.
3. Location of Service - Emergency medical services must have been provided by a physician in
a general acute care hospital which meets one of the following conditions:
• The hospital has a permit to provide basic or comprehensive emergency medical services;
or,
• The hospital has a permit for standby emergency services prior to July 1, 1991 and meets
the criteria as a"small and rural hospital"as defined in Section 124840 of the Health and
Safety Code.
Eligible Hospitals for Funds As of 7/1/91
Basic Emergency Department Rural Standby Emergency Department
Clovis Community Hospital Coalinga District Hospital
Community Regional Medical Center,Fresno Kingsburg District Hospital
Kaiser Hospital Selma District Hospital
Saint Agnes Medical Center Sierra Kings District Hospital(Reedley)
D. Patient Eligibility
Reimbursement under this claiming process shall be limited to services for which the physician,
following reasonable billing efforts(as discussed below), has not received any payment from a
patient or responsible party, and the patient does not have health insurance for emergency services
and care, cannot afford to pay for those services, and for whom payment will not be made through
any private coverage or by any program funded in whole or in part by the federal government with
Exhibit C
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SUBJECT: Physician Services Account(PSA)—Reimbursement Claim Procedures—August 28,2013
PSA 001
the exception of claims submitted for reimbursement through Section 1011 of the federal Medicare
Prescription Drug, Improvement and Modernization Act of 2003.
These procedures shall not be applied or interpreted so as to prevent a physician from seeking or
accepting payment from a patient or responsible third-party payor, or arranging a repayment
schedule for the costs of services rendered prior to receiving payment from this fund.
E. Claim Eligibility
Physicians must make reasonable efforts to bill for services provided. Claims are eligible for
reimbursement through this fund if all of the following conditions are met:
1. The physician has inquired if there is a responsible third-party source of payment.
2. The physician has billed the patient and, if identified, a responsible third party for payment of
services.
3. The physician has made reasonable efforts to collect payment(the physician's records should
maintain evidence of such effort). For purposes of the PSA,reasonable efforts shall be
defined as one of the following:
• A period of not less than three(3) months has passed since the initial billing, and there
has been a minimum of three(3)billings by the physician (the three billing requirement
is waived if a billing is returned by postal authorities marked"no known forwarding
address" or"addressee unknown"and the physician made reasonable efforts to discover a
correct billing address); or
• The physician has received actual notification from the patient or responsible third party
that no payment will be made for the services rendered by the physician.
4. Claims are submitted within three (3) months of the date of service quarter ending date.
Supplemental or extended submission periods may be announced periodically in writing by
the Fresno County Department of Public Health.
5. The physician has not received reimbursement of any portion of the amount billed to the
patient. Deposits for services made by the patient or responsible party are considered partial
payments and result in the service not being eligible for reimbursement under this program.
Deposits for specific services will apply only towards that specific service and will not affect
other claims for different services for that same patient on different dates.
Physicians must stop any current, and waive any future,collection efforts to obtain reimbursement
from the patient, upon receipt of funds from the PSA.
Exhibit C
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SUBJECT: Physician Services Account(PSA)—Reimbursement Claim Procedures—August 28,2013
PSA 001
III. CLAIMS PROCESS
The DPH Business Office reviews each claim and determines the most appropriate criteria to process the
claim for reimbursement. The process includes the following guidelines:
A. Funding Source
When a claim meets eligibility for the Maddy(EMS)funding source, claims will be eligible for
reimbursement to the extent that funds are available from that funding source
B. Fee Schedule
The County utilizes the Medicare Resource-Based Relative Value Scale (RBRVS)as its payment
methodology. All eligible claims will be reimbursed on a proportional basis dependent on the
number of eligible claims received and available funding.
C. Claims Submission
Claims documents must be submitted to the County of Fresno, Department of Public Health,
Business Office, P. O. Box 11867, Fresno, CA 93775
NOTE: For information on claims status or submission, contact the Department of Public
Health Business Office at(559) 600-6415.
D. Claim Submission Period
All claims for services provided must be submitted no later than three (3) months from the date of
services quarter ending date. Supplemental or extended submission periods may be announced
periodically, in writing, by the Department of Public Health.
E. Medically Indigent Care Reporting System (MICRS) Incident/Service Form
Claims must be submitted on a MICRS Incident/Service Form (refer to Attachment Q. This form
must be legible and accurately completed in order for the claim to be eligible for reimbursement. A
separate claim form must be utilized for each claim. A claim consists of services on a single day by a
single physician for the same patient, same service setting, and type of service. This form is also
used for non-physician providers; therefore, some data elements may not apply.
Each batch of claim forms should be grouped together in no more than 20 claims per batch and must
be accompanied by a"MICRS Control Sheet"(Attachment D). DO NOT fax claims.
NOTE: For information on electronic submission, contact the Department of Public Health
Information Systems Division at(559) 600-6479.
The MICRS Incident/Service Form must include, unless otherwise noted, all of the following data
elements(see Attachment D):
Exhibit C
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SUBJECT: Physician Services Account(PSA)—Reimbursement Claim Procedures—August 28,2013
PSA 001
1. Provider Information
Provider Number: Mandatory for all claims. The provider number is the physician's
California medical license number.
a. Provider Name: Mandatory for all claims.
b. Group Number: If applicable (for physician groups).
c. Group Name: If applicable (for physician groups).
2. Patient Information
a. Driver's License Number/State: If available.
b. Social Security Number: If available.
c. Patient Chart Number: Mandatory for all claims.
d. Date of Birth: Mandatory for all claims.
e. Patient Name: Mandatory for all claims.
f. Sex: Mandatory for all claims.
g. Street Address: If available.
h. Apartment/Suite/Building Number: If available.
i. City: If available.
j. State: If available.
k. Zip Code (Residence): Mandatory for all claims.
99997—Not applicable: Use when the patient has no known address.
99998 — Unknown: Use when the patient does not know, refuses to divulge, or cannot
communicate the information.
99999—Missing: Use when the patient zip code has been omitted from the input
document for some reason other than described above.
1. Telephone Number: If available.
m. Family Size: If available.
Exhibit C
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SUBJECT: Physician Services Account(PSA) -Reimbursement Claim Procedures—August 28,2013
PSA 001
n. Ethnicity: Mandatory for all claims. Select from the list of codes on the back of the
form.
o. Monthly Family Income: If available.
p. Primary Source of Income: If available.
q. Type of Employment: If available.
r. ELA Alien Number: If available.
s. ELA Section Number: If available.
t. ELA Document Type: If available.
u. ELA Issue Date: If available.
v. ELA Expiration Date: If available.
3. Incident/Service Information
a. Incident/Admit Date: Mandatory for all claims. The date on which the services were
provided.
b. Claim Amount: Mandatory for all claims.
c. Service Setting: Mandatory for all claims. Select from the list of codes on the MICRS
Incident/Service Form Reference Codes (Attachment E).
d. Service Setting Zip Code: Mandatory for all claims.
e. PSA Visit Type: Mandatory for all claims. Select from the list of codes on Attachment
E - MICRS Incident/Service Form Reference Codes.
4. Inpatient Service (within 48 hours)— Required for inpatient services
a. Procedure/Service (CPT-4 Codes): Mandatory for all claims.
b. Discharge Diagnosis (ICD-9-CM Codes): Mandatory for all claims.
c. Discharge Date: Mandatory for inpatient services.
d. Service Location: Mandatory for inpatient services. Select from the list of codes on
MICRS Incident/Service Form Reference Codes (Attachment E). Reimbursement for
emergency care is limited to services provided at the hospitals listed in Section IIC3.
e. Admitting Hospital Type: Not Applicable.
5. Emergency Room Service (within 48 hours)—Required for emergency department services
Exhibit C
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SUBJECT: Physician Services Account(PSA)—Reimbursement Claim Procedures—August 28,2013
PSA 001
a. Principal Diagnosis(ICD—9-CM Codes): Mandatory for all claims.
b. Procedure/Service(CPT-4 Codes): Mandatory for all claims.
ER Service and Disposition: Mandatory for emergency department services. Select
from the list of codes on MICRS Incident/Service Form Reference Codes (Attachment
E).
Admitting Hospital Type: Not Applicable.
Service Location: Mandatory for emergency department services: Select from the list
of codes on MICRS Incident/Service Form Reference Codes (AttacIVnent E).
Reimbursement for emergency care is limited to services provided at the hospitals listed
in Section IIC3.
6. Expenditures
a. Date Paid: Not required.
b. Amount Paid: Mandatory for all claims. This is the amount paid by the patient or
responsible third party.
NOTE: If more than $0, the claim will not qualify for reimbursement— refer to Section
IIE5.
c. Payment Source: Not required.
F. Suspended Claims
The provider will review the Suspended Items Report which identifies denied claims that have been
suspended. Suspended claims may be resubmitted with all necessary documentation within two
weeks of notification to the provider representative that the report has been posted on the County's
FPT server(Attachment F).
G. Potential Duplicate Claims
The provider will review the Potential Duplicate Claims Report and will identify duplicate claims to
be withdrawn and will notify the DPH Business Office within two weeks of notification to the
provider representative that the report has been posted on the County's FPT server(Attachment G).
H. Withdrawing Claims
The provider will review the Withdraw Report and will identify any claims to be withdrawn and will
notify the DPH Business Office within two weeks of notification to the provider representative that
the report has been posted on the County's FPT server(Attachment H).
Exhibit C
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SUBJECT: Physician Services Account(PSA)—Reimbursement Claim Procedures—August 28,2013
PSA 001
I. Modification of Claims
Modification of a claim due to an error in the stated billing amount shall be done on a MICRS
Supplemental Claim Form (Attachment I). This form must be submitted within six (6)months of the
date of service.
IV. COUNTY LIABILITY/PAYMENT
A. Availability of Monies in County Physician Services Account
Payment of any claims under this claiming process is contingent upon the availability of monies
deposited in the Fresno County PSA. To the extent that the monies are available, valid claims
presented to the County will be paid at a prorated amount. The payment rate will be based on the
Medicare RBRVS Fee Schedule and will be calculated each quarter by dividing the total dollars
available in the appropriate fund by the total dollar value of all valid claims. Valid claims will be
paid by the County quarterly, up to a maximum of 50%of the amount claimed for the initial cycle of
reimbursements. All funds remaining at the end of the fiscal year shall be distributed proportionally,
based on the dollar amount of claims submitted and paid to all physicians who submitted qualifying
claims during the year.
B. Payment Schedule
1. Claims submitted will be grouped according to dates of service within each calendar quarter
(three (3) month time blocks). Funds available for disbursement for each block will be
disbursed based upon the percentage determined in Section IVA above.
2. The payment schedule will be based on the following calendar quarter date of service blocks:
DATE OF SERVICE BLOCK
July 1—September 30 1" Quarter
October I—December 31 2id Quarter
January I—March 31 3`d Quarter
April I—June 30 4"' Quarter
C. Remittance Information
PSA remittance information and reports will be made available on the County of Fresno secured File
Transfer Protocol (FTP) server. Provider representatives will be given a password and server
address to connect directly to their specific electronic folder where remittance information and
reports can be printed, downloaded, or saved. Files will be retained and available in this location for
two weeks from the date of notification to provider representative that files are available. The files
will be deleted two weeks after notification to the provider representative.
D. Physician Collection Efforts and Refunds
Upon receipt of payment from the PSA, the physician shall discontinue any current efforts and waive
any future efforts to obtain reimbursement from the patient or a responsible party. If a physician,
Exhibit C
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SUBJECT: Physician Services Account(PSA)—Reimbursement Claim Procedures—August 28,2013
PSA 001
after receiving payment from the PSA, is reimbursed by a patient or responsible party, the physician
shall do one of the following within 30 days:
1. Notify the DPH Business Office. The DPH Business Office shall reduce the physician's
future payment of claims from the account. In the event there is not a subsequent submission
of a claim for reimbursement within one year, the physician shall reimburse the account in an
amount equal to the amount collected from the patient or third-party payer, but not more than
the amount of reimbursement received from the account; or,
2. Notify the DPH Business Office of the payment and, reimburse the account in an amount
equal to the amount collected from the patient or third-party payer,but not more than the
amount of the reimbursement received from the account for that patient's care.
The notification shall be documented on the MICRS Incident/Service Supplemental Claim
Form(Attachment I) and should include the patient's ID number, the original date of service,
the amount paid by both the patient/third party payer and PSA,the MICRS incident number,
the physician and, if applicable, group ID number.
3. In the event the physician receives payment from any source on a claim that has been
submitted to the DPH Business Office, but has not yet been reimbursed from the PSA,the
physician shall contact the DPH Business Office and request that the claim be withdrawn
from the program.
E. Records/Audit/Adjustment
In addition to any physician duties listed previously herein, claimants using this claiming process are
obligated as follows:
1. The physician shall immediately prepare and thereafter maintain complete and accurate
records sufficient to fully and accurately reflect the services and costs thereof, for which
claims have been made. Such records shall include, but not be limited to patient name and
identifying information, services provided, duties of service(s) and patient service charges.
Additionally, such records shall include evidence of all billing efforts required by this
claiming process.
2. All such records shall be retained by the physician at a location in Fresno County for
a minimum of three(3) years following the date(s)of service.
3. Such records shall be made available to representatives of the Fresno County
Department of Public Health,the DPH Business Office, and the Fresno County
Auditor-Controller, or to representatives of the State, upon request,at all reasonable
times during such three(3)year period for the purpose of inspection,audit and
copying.
4. If an audit conducted by County or State representatives, of physician or hospital
records, or both, relating to the services for which claim was made and paid
hereunder, finds that(1)the records do not support the nature of all or a portion of the
Exhibit C
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SUBJECT: Physician Services Account(PSA)—Reimbursement Claim Procedures—August 28,2013
PSA 00l
service, or(2)records do not evidence the provision of all or a portion of the service,
or(3)the physician failed either to report or remit payments from other sources as
required herein, the physician shall, upon receipt of County billing therefore, remit
forthwith to the County the audit adjustment amount improperly billed to and paid by
the County.
5. A physician who submits any claim for reimbursement which is inaccurate or which
is not supported by records may be excluded from reimbursement of future claims
from the PSA upon the determination of the Fresno County Director of Public Health.
F. Dispute Resolution
Disputes which occur regarding claim eligibility are generally resolved through discussions between
the physician's billing staff and PSA program administration staff. If a physician/group believes that
a dispute continues to exist after a final decision by PSA staff(after claim resubmission), the
physician/group may submit a written request for a review of the decision. This written request must
be submitted to the Department of Public Health within forty-five(45) days of the deadline for
claims submission for the payment quarter and should specifically state the issue and why the
physician/group feels that the claim is eligible for reimbursement. PSA staff will forward the written
request for review to a local medical society for resolution by neutral parties.
Exhibit C
Page 35 of 64
ATTACHMENT A
COUNTY OF FRESNO—DEPARTMENT OF PUBLIC HEALTH
APPLICATION FOR PROVIDER STATUS FOR PHYSICIAN SERVICES ACCOUNT
UNCOMPENSATED CARE PROGRAM
TO: County of Fresno
Department of Public Health, Business Office
P.O. Box 11867
Fresno,CA 93775
This application is submitted by the undersigned physician(hereinafter called"Physician")for the purpose of submitting
claims for uncompensated care consisting of medically necessary emergency services he/she has rendered to patients
according to the requirements of the State of California and County of Fresno. Claims are for services for which the
physician has not received any payment from a patient,or a responsible relative,and the patient does not have medical
coverage by a third-party payer for such services.
Physicians and surgeons are eligible to receive payment for patient care services by or in conjunction with a properly
credentialed nurse practitioner or physician's assistant for care rendered under the direct supervision of the physician or
surgeon.
Physician acknowledges receipt of a copy of the Fresno County Department of Public Health's"Physician Services Account
Reimbursement Claim Procedures"(hereinafter called"Claim Procedures"),the terms and conditions of which are
incorporated herein by reference. Physician hereby certifies that he/she has and will comply fully with the claiming
conditions stated therein,and as may be amended from time to time, in submitting this application and claims. These
physician billing requirements,duties,and obligations, including,but not limited to,the preparation,maintenance,and
retention of service and financial records,and their availability for audit, will be observed by him/her.
Physician certifies that the information submitted supporting claims against the Emergency Medical Services Fund or the
Physician Services Account is true,accurate,and complete and demonstrates a reasonable effort to identify eligibility for a
third-party payer source. Based upon that effort and the available information,the physician agrees to only submit claims for
patients who do not have medical coverage by a third-party payer,and for services for which the physician has made a
reasonable effort to bill and collect for services,and has not received Lny payment.
Physician acknowledges that County payment on this claim is contingent upon the availability of funds in the Fresno County
Emergency Medical Services Fund and Physician Services Account and the conditions for payment described in the
California Health and Safety Code, Welfare and Institutions Code,and claim procedures of the County of Fresno. Physician
additionally acknowledges that the County of Fresno is not responsible for full or partial payment of this claim should funds
be unavailable from the Emergency Medical Services Fund or the Physician Services Account.
Physician expressly acknowledges and understands that this application,any claims submitted,and any County liability
therefore, is subject to the conditions defined in the Claim Procedures, including,among others,the results of audits and
adjustments.
As part of this application, Physician, in accordance with instructions defined in the Claim Procedures,has completed and
attached the"Physician Personal Data Form".
Physician certifies that the application information submitted herewith is true,accurate,and complete to the best of his/her
knowledge.
BY: DATE:
Typed or Printed Name of Physician
Signature of Physician
Rev. 8/28/13
Exhibit C
Page 36 of 64
a
ATTACHMENT B
COUNTY OF FRESNO—DEPARTMENT OF PUBLIC HEALTH
PHYSICIAN PERSONAL DATA FORM
I. APPLICANT NAME:
2. PHYSICIAN LICENSE NUMBER:
3. PHYSICIAN NPI NUMBER:
4. EXPIRATION DATE(MM/DD/YY):
5. IF APPLYING AS A PART OF A PHYSICIAN'S GROUP,LIST THE NAME OF THE GROUP:
6. BUSINESS ADDRESS:
7. BUSINESS TELEPHONE: L)
8. PRIMARY SPECIALTY OF PHYSICIAN:
9. INDICATE PRESENT BILLING ARRANGEMENT OR CONTRACT WITH HOSPITAL WHERE SERVICES FOR
CLAIMS WILL BE MADE(Check one or more boxes):
❑ Employee of the hospital
❑ Physician retained for patient care services by facility.
❑ Contract with facility to bill fee for service on the physician's behalf.
❑ Physician retained only for administration,teaching and/or supervision of facility.
❑ Fee for service only for compensation for direct patient care.
10. PLEASE LIST LOCATION(S)(e.g.hospital)AND ADDRESS WHERE SERVICES WILL BE PROVIDED(List
hospital name; if other than hospital, list address):
As a condition to claiming reimbursement from the County of Fresno Physician Services Account, I certify that the above
information is true,accurate and complete to the best of my knowledge.
Typed or Printed Name of Physician Date
Signature of Physician Tax I.D.Number
ATTACHMENT C
Exhibit C
FRESNO COUNTY DEPARTMENT OF PUBLIC HEALTAof64
MICRS INCIDENT/SERVICE FORM
PROVIDER INFORMATION
Provider No: Provider Name:
Group No: Group Name:
PATIENT INFORMATION
Driver's License State: Social Security No:
No:
Chart No: Date of Birth: Patient Name(Last,First,Middle,Suffix): Sex:
Street Address: Apt/Suite/Bldg.:
City: State: Zip Code: Telephone No.:
Family Size: Ethnicity: Monthly Income: Source of Income: Type of Employment:
ELA Alien No.: Section: Document Type: Issue Date: Expiration Date:
INCIDENT/SERVICE INFORMATION
Incident/Admit Date: Claim Amount: COUNTY USE ONLY Service Setting: Service Setting"Lip Code:
$ Incident Type:
COUNTY USE ONLY PSA Visit Type:
Date Claim Received:
(3) Emergency Room Service
within 48 hours
Principal Diagnosis(ICD-9-CM Codes):(5 digits)
Procedure/Servic CPT4 Codes):
ER Srv/Disp: Admit Hosp Type: Service Location:
(2) Inpatient Service (within 48 hours)
Procedure/Servicc(CPT4 Codes):
Discharge Diagnosis(ICD-9-CM Codes): (5 digits)
Discharge Date: Service Location: Admit Hosp Type:
Expenditures
Date Paid: Amount Paid: Payment Source:
COUNTY USE
FCDPH,08-28-13
Batch No: Patient No: Incident No:
MICRS INCIDENT/SERVICE FORM
Exhibit C
ATTACHMENT D Page 38 of 64
FRESNO COUNTY DEPARTMENT OF PUBLIC HEALTH
MEDICALLY INDIGENT CARE REPORTING SYSTEM(MICRS)
MICRS CONTROL SHEET
DATE:
GROUP OR PHYSICIAN NAME:
GROUP OR PHYSICIAN IDENTIFICATION NUMBER:
CLAIMS QUARTER AND FISCAL YEAR:
INCIDENT NUMBER OF NUMBER OF CLAIMS AMOUNT CLAIMED
TYPE PATIENTS
INPATIENT $
EMERGENCY ROOM $
TOTAL $
Exhibit C
Page 39 of 64
ATTACHMENT E
MICRS INCIDENT/SERVICE FORM-REFERENCE CODES
Group No. Provider No.
Medical groups,who submit claims under MICRS,must have a I lospitals: Enter your state issued OSHPD number.
group identification number issued by Fresno County. If your Physicians and other providers:Enter your state license number.
group is not currently registered,contact DPI{Business Office at
(559)600-6415. Type of Employment Codes
1. Executive,Administrative,Managerial,Professional,Technical
Source of Income Codes 2. Production,Inspection,Repair,Transportation,Craft,
Handlers,Helpers,Laborers
I. None 5. General/Public Assistance 3. Sales,Service
2. Earned 6. Other(e.g.Child Support, 4. Farming,Forestry,Fishing
3. Disability Interest,Rental Income) 5. Unemployed
4. Retirement 7. Unknown 9. Unknown
Ethnicity Code Eli ibg le Legalized Alien Section Codes
1. White 5. Asian/Pacific Islander 245A-Section 245A
2. Black 6. Other 2 10A
3, Hispanic 7. Unknown 210-Section 210A-Section 2
4. Native American/Eskimo,
210
Aleut
Eligible Legalized Alien Document Type Codes Expenditure Payment Source Codes
I-94 -INS Document Type 1-94 1. Self-Pay(includes collected 5. CHIP/RHS
1-551 -INS Document Type 1-551 share of cost amounts) 6. MISP
I-688 -INS Document Type 1-688 2. Private Insurance 7. Other Section 17000
I-688A -INS Document Type I-688A 3. Medicare 8. Other
I-688B -INS Document Type 1-688B 4. Medi-Cal 9. Unknown
I-689 -INS Document Type 1-689
1-693 -INS Document Type 1-693 Service Location
OTHER -OTHER INS Document Type If services are rendered by a provider at another provider's service
location(i.e.,at another hospital),a service location number for that
site must be entered on the MICRS Incident/Service Form.
Service Setting Codes
(Codes 3. 4, 5 not valid)
1. Hospital-ER For hospital service settings,enter a service location(OSHPD)
2. Hospital-Outpatient number from those listed below for Fresno County(contact DPH
6. Hospital Inpatient Business Office at(559)600-6415 for out-of-County listings):
104008-Community Behavioral 100743-Kings View
PSA Visit Type Codes Health Center 100793-Selma District
I. Physician Emergency (Within 48 Hours) 100697-Coalinga Regional 100797-Adventist Medical
Medical Center Center
Emergency Room Service and Disposition Codes 100717-Community Regional
1. Non-emergency,Released from Ilospital Medical Center
2. Emergency,Released from Hospital or Deceased 100745-Kingsburg Med Ctr
3. Emergency,Released from Hospital or Deceased 100899-St.Agnes Med Ctr
4. Non-emergency,Transferred to Another Hospital 100822-University Medical Ctr
5. Emergency,Transferred to Another Hospital100005-Clovis Community
6. Non-emergency,Admitted to Hospital
7. Emergency,Admitted to Hospital
Admitting Hospital'Type Codes
1. County
2. Contract
3. University Teaching
4. Other Non-County,Non-Contract
ATTACHMENT F Exhibit C
Page 40 of 64
RPT NUMBER: SUSPITEMPSA FRESNO COUNTY DEPARTMENT OF HEALTH
QAWEBMICRS SUSPENDED ITEMS REPORT PAGE 2
PHYSICIAN SERVICES ACCOUNT
04/01/2010 thru 06/30/2010
GROUP NAME GROUP NBR PROVIDER NAME PROVE) NBR
ACME GROUP 2 WILSON, HENRY A108391
PATIENT NAME MED REC # INCD ACCT # PATIENT NBR
CHART NBR
BROWN, PETER 32819 32819 248 300
INCIDENT NBR BATCH NBR INCIDENT DATE TYPE OF SERVICE AMOUNT
CLAIMED CLAIM TYPE CONTRACT CODE
45583 901 06/01/2010 INPATIENT 110
SUSPENSE NBR SUSPENSE CODE FIELD IN ERROR FIELD
VALUE CORRECTED VALUE
19357 MISSING DATA DISCHARGE DATE
GROUP NAME GROUP NBR PROVIDER NAME PROVD NBR
ACME GROUP 2 WILSON, HENRY A108391
PATIENT NAME MED REC # INCD ACCT # PATIENT NBR
CHART NBR
MILLER, JOYCE 29796 29796 6921 211
INCIDENT NBR BATCH NBR INCIDENT DATE TYPE OF SERVICE AMOUNT
CLAIMED CLAIM TYPE CONTRACT CODE
45566 900 05/22/2010 EMERGENCY RM 110
SUSPENSE NBR SUSPENSE CODE FIELD IN ERROR FIELD
VALUE CORRECTED VALUE
19348 MISSING DATA EMRG RM DISP
Exhibit C
Page 41 of 64
ATTACHMENT G
RPT NUMBER: DUPCLAIMS FRESNO COUNTY DEPARTMENT OF HEALTH 03/13/2013
POTENTIAL DUPLICATE CLAIMS REPORT
FROM 04/01/2010 TO 06/30/2010
GROUP NAME PROVD NAME PATIENT NAME DOB TYPE SVC
DT SVC SET CLM AMT
ACME GROUP WILSON,HENRY BROWN,PETER 07/01/59 2
05/25/2010 6 273.00
INCIDENT NBR: 30574 BATCH NBR: 67
INCIDENT NBR: 30580 BATCH NBR: 67
ACME GROUP WILSON,HENRY BROWN,PETER 07/01/59 2
05/25/2010 6 469.00
INCIDENT NBR: 30578 BATCH NBR: 67
INCIDENT NBR: 30586 BATCH NBR: 67
ACME GROUP WILSON,HENRY BROWN,PETER 07/01/59 2
05/25/2010 6 657.00
INCIDENT NBR: 30577 BATCH NBR: 67
INCIDENT NBR: 30585 BATCH NBR: 67
ACME GROUP WILSON,HENRY BROWN,PETER 07/01/59 2
05/25/2010 6 860.00
INCIDENT NBR: 30576 BATCH NBR: 67
INCIDENT NBR: 30584 BATCH NBR: 67
ACME GROUP WILSON,HENRY MILLER,JOYCE 03/01/85 2
05/24/2010 6 229.00
INCIDENT NBR: 30755 BATCH NBR: 67
INCIDENT NBR: 30756 BATCH NBR: 67
ACME GROUP WILSON,HENRY MILLER,JOYCE 03/01/85 2
05/24/2010 6 229.00
INCIDENT NBR: 30756 BATCH NBR: 67
INCIDENT NBR: 30757 BATCH NBR: 67
Exhibit C
Page 42 of 64
Attachment H
Withdraw Report
3rd qtr 2009/10
Incident# Provider# Provider Name Record# Patient Name Birthdate Encounter Date Claim$
10000 A10000 SMITH I DOE,JOHN 10/01/1975 01/26/2010 66.94
10001 A10000 SMITH 2 JONES,SAM 01/01/1953 03/10/2010 422.71
10002 A10000 SMITH 3 JOHNSON, DON 03/01/1948 03/10/2010 237.80
10003 A10000 SMITH 4 WILLIAMS,TAYLOR 12/01/1956 03/31/2010 68.32
Exhibit C
Page 43 of 64
ATTACHMENT 1
FRESNO COUNTY DEPARTMENT OF PUBLIC HEALTH
MEDICALLY INDIGENT CARE REPORTING SYSTEM(MICRS)
MICRS INCIDENT/SERVICE SUPPLEMENTAL CLAIM FORM
(Note: Use this Form Only to Correct Claimed Billing Amount)
PROVIDER IDENTIFICATION
GROUP NAME:
GROUP IDENTIFICATION NUMBER:
PHYSICIAN NAME:
PHYSICIAN LICENSE NUMBER:
MICRS INCIDENT NUMBER(IF KNOWN):
PATIENT IDENTIFICATION
PATIENT NAME:
PATIENT CHART NUMBER:
DATE OF BIRTH: SEX:
INCIDENT IDENTIFICATION
DATE OF SERVICE(INCIDENT DATE):
TYPE OF SERVICE(CHECK ONLY ONE):
INPATIENT
EMERGENCY ROOM
SERVICE SETTING(CHECK ONLY ONE):
HOSPITAL EMERGENCY ROOM
HOSPITAL OUTPATIENT
HOSPITAL INPATIENT
PSA VISIT TYPE:
PHYSICIAN EMERGENCY(WITHIN 48 HOURS)
REQUESTED BILLING AMOUNT CHANGE
INITIAL AMOUNT BILLED TO COUNTY: $
CORRECTED AMOUNT BILLED TO COUNTY: $
REASON FOR CHANGE(REQUIRED):
18-013 EXHIBIT B
Exhibit C
Page 44 of 64
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HEALTH AND SAFETY CODE-HSC
DIVISION 2.5. EMERGENCY MEDICAL SERVICES [1797-1799.207] (Division 2.5 added by Stats. 1980, Ch. 1260.)
CHAPTER 2.5.The Maddy Emergency Medical Services Fund [1797.98a-1797.98g] (Heading of Chapter 2.5
amended by Stats. 1998, Ch. 58, Sec. 2. )
1797.98a. (a) The fund provided for in this chapter shall be known as the Maddy Emergency Medical Services
(EMS) Fund.
(b) (1) Each county may establish an emergency medical services fund, upon the adoption of a resolution by the
board of supervisors. The moneys in the fund shall be available for the reimbursements required by this chapter.
The fund shall be administered by each county, except that a county electing to have the state administer its
medically indigent services program may also elect to have its emergency medical services fund administered by
the state.
(2) Costs of administering the fund shall be reimbursed by the fund in an amount that does not exceed the
actual administrative costs or 10 percent of the amount of the fund, whichever amount is lower.
(3) All interest earned on moneys in the fund shall be deposited in the fund for disbursement as specified in this
section.
(4) Each administering agency may maintain a reserve of up to 15 percent of the amount in the portions of the
fund reimbursable to physicians and surgeons, pursuant to subparagraph (A) of, and to hospitals, pursuant to
subparagraph (B) of, paragraph (5). Each administering agency may maintain a reserve of any amount in the
portion of the fund that is distributed for other emergency medical services purposes as determined by each
county, pursuant to subparagraph (C) of paragraph (5).
(5) The amount in the fund, reduced by the amount for administration and the reserve, shall be utilized to
reimburse physicians and surgeons and hospitals for patients who do not make payment for emergency medical
services and for other emergency medical services purposes as determined by each county according to the
following schedule:
(A) Fifty-eight percent of the balance of the fund shall be distributed to physicians and surgeons for emergency
services provided by all physicians and surgeons, except those physicians and surgeons employed by county
hospitals, in general acute care hospitals that provide basic, comprehensive, or standby emergency services
pursuant to paragraph (3) or (5) of subdivision (f) of Section 1797.98e up to the time the patient is stabilized.
(B) Twenty-five percent of the fund shall be distributed only to hospitals providing disproportionate trauma and
emergency medical care services.
(C) Seventeen percent of the fund shall be distributed for other emergency medical services purposes as
determined by each county, including, but not limited to, the funding of regional poison control centers. Funding
may be used for purchasing equipment and for capital projects only to the extent that these expenditures
support the provision of emergency services and are consistent with the intent of this chapter.
18-013 EXHIBIT B
Exhibit C
(c) The source of the moneys in the fund shall be the penalty assessment made for this purpose, as provided in
Section 76000 of the Government Code. Page 45 of 64
(d) Any physician and surgeon may be reimbursed for up to 50 percent of the amount claimed pursuant to
subdivision (a) of Section 1797.98c for the initial cycle of reimbursements made by the administering agency in
a given year, pursuant to Section 1797.98e. All funds remaining at the end of the fiscal year in excess of any
reserve held and rolled over to the next year pursuant to paragraph (4) of subdivision (b) shall be distributed
proportionally, based on the dollar amount of claims submitted and paid to all physicians and surgeons who
submitted qualifying claims during that year.
(e) Of the money deposited into the fund pursuant to Section 76000.5 of the Government Code, 15 percent shall
be utilized to provide funding for all pediatric trauma centers throughout the county, both publicly and privately
owned and operated. The expenditure of money shall be limited to reimbursement to physicians and surgeons,
and to hospitals for patients who do not make payment for emergency care services in hospitals up to the point
of stabilization, or to hospitals for expanding the services provided to pediatric trauma patients at trauma
centers and other hospitals providing care to pediatric trauma patients, or at pediatric trauma centers, including
the purchase of equipment. Local emergency medical services (EMS) agencies may conduct a needs assessment
of pediatric trauma services in the county to allocate these expenditures. Counties that do not maintain a
pediatric trauma center shall utilize the money deposited into the fund pursuant to Section 76000.5 of the
Government Code to improve access to, and coordination of, pediatric trauma and emergency services in the
county, with preference for funding given to hospitals that specialize in services to children, and physicians and
surgeons who provide emergency care for children. Funds spent for the purposes of this section shall be known
as Richie's Fund. This subdivision shall remain in effect until January 1, 2027.
(f) Costs of administering money deposited into the fund pursuant to Section 76000.5 of the Government Code
shall be reimbursed from the money collected in an amount that does not exceed the actual administrative costs
or 10 percent of the money collected, whichever amount is lower. This subdivision shall remain in effect until
January 1, 2027.
(Amended by Stats. 2016, Ch. 147, Sec. 2. Effective January 1, 2017.)
1797.98b. (a) Each county establishing a fund, on January 1, 1989, and on each April 15 thereafter, shall report
to the authority on the implementation and status of the Emergency Medical Services Fund. Notwithstanding
Section 10231.5 of the Government Code, the authority shall compile and forward a summary of each county's
report to the appropriate policy and fiscal committees of the Legislature. Each county report, and the summary
compiled by the authority, shall cover the immediately preceding fiscal year, and shall include, but not be limited
to, all of the following:
(1) The total amount of fines and forfeitures collected, the total amount of penalty assessments collected, and
the total amount of penalty assessments deposited into the Emergency Medical Services Fund, or, if no moneys
were deposited into the fund, the reason or reasons for the lack of deposits. The total amounts of penalty
assessments shall be listed on the basis of each statute that provides the authority for the penalty assessment,
including Sections 76000, 76000.5, and 76104 of the Government Code, and Section 42007 of the Vehicle Code.
(2) The amount of penalty assessment funds collected under Section 76000.5 of the Government Code that are
used for the purposes of subdivision (e) of Section 1797.98a.
(3) The fund balance and the amount of moneys disbursed under the program to physicians and surgeons, for
hospitals, and for other emergency medical services purposes, and the amount of money disbursed for actual
administrative costs. If funds were disbursed for other emergency medical services, the report shall provide a
description of each of those services.
(4) The number of claims paid to physicians and surgeons, and the percentage of claims paid, based on the
uniform fee schedule, as adopted by the county.
(5) The amount of moneys available to be disbursed to physicians and surgeons, descriptions of the physician
and surgeon claims payment methodologies, the dollar amount of the total allowable claims submitted, and the
percentage at which those claims were reimbursed.
(6) A statement of the policies, procedures, and regulatory action taken to implement and run the program
under this chapter.
(7) The name of the physician and surgeon and hospital administrator organization, or names of specific
18-013 EXHIBIT B
Exhibit C
physicians and surgeons and hospital administrators, contacted to review claims payment methodologies.
Page 46 of 6
(8) A description of the process used to solicit input from physicians and surgeons and hospitals to review
payment distribution methodology as described in subdivision (a) of Section 1797.98e.
(9) An identification of the fee schedule used by the county pursuant to subdivision (e) of Section 1797.98c.
(10) (A) A description of the methodology used to disburse moneys to hospitals pursuant to subparagraph (B) of
paragraph (5) of subdivision (b) of Section 1797.98a.
(B) The amount of moneys available to be disbursed to hospitals.
(C) If moneys are disbursed to hospitals on a claims basis, the dollar amount of the total allowable claims
submitted and the percentage at which those claims were reimbursed to hospitals.
(11) The name and contact information of the entity responsible for each of the following:
(A) Collection of fines, forfeitures, and penalties.
(B) Distribution of penalty assessments into the Emergency Medical Services Fund.
(C) Distribution of moneys to physicians and surgeons.
(b) (1) Each county, upon request, shall make available to any member of the public the report provided to the
authority under subdivision (a).
(2) Each county, upon request, shall make available to any member of the public a listing of physicians and
surgeons and hospitals that have received reimbursement from the Emergency Medical Services Fund and the
amount of the reimbursement they have received. This listing shall be compiled on a semiannual basis.
(Amended by Stats. 2014, Ch. 442, Sec. 5. Effective September 18, 2014.)
1797.98c. (a) Physicians and surgeons wishing to be reimbursed shall submit their claims for emergency services
provided to patients who do not make any payment for services and for whom no responsible third party makes
any payment.
(b) If, after receiving payment from the fund, a physician and surgeon is reimbursed by a patient or a
responsible third party, the physician and surgeon shall do one of the following:
(1) Notify the administering agency, and, after notification, the administering agency shall reduce the physician
and surgeon's future payment of claims from the fund. In the event there is not a subsequent submission of a
claim for reimbursement within one year, the physician and surgeon shall reimburse the fund in an amount equal
to the amount collected from the patient or third-party payer, but not more than the amount of reimbursement
received from the fund.
(2) Notify the administering agency of the payment and reimburse the fund in an amount equal to the amount
collected from the patient or third-party payer, but not more than the amount of the reimbursement received
from the fund for that patient's care.
(c) Reimbursement of claims for emergency services provided to patients by any physician and surgeon shall be
limited to services provided to a patient who does not have health insurance coverage for emergency services
and care, cannot afford to pay for those services, and for whom payment will not be made through any private
coverage or by any program funded in whole or in part by the federal government, with the exception of claims
submitted for reimbursement through Section 1011 of the federal Medicare Prescription Drug, Improvement and
Modernization Act of 2003, and where all of the following conditions have been met:
(1) The physician and surgeon has inquired if there is a responsible third-party source of payment.
(2) The physician and surgeon has billed for payment of services.
(3) Either of the following:
(A) At least three months have passed from the date the physician and surgeon billed the patient or responsible
third party, during which time the physician and surgeon has made two attempts to obtain reimbursement and
has not received reimbursement for any portion of the amount billed.
(B) The physician and surgeon has received actual notification from the patient or responsible third party that no
payment will be made for the services rendered by the physician and surgeon.
(4) The physician and surgeon has stopped any current, and waives any future, collection efforts to obtain
18-pX�,
��HIMT B
reimbursement from the patient, upon receipt of moneys from the fund. Page 47 of 64
(d) A listing of patient names shall accompany a physician and surgeon's submission, and those names shall be
given full confidentiality protections by the administering agency.
(e) Notwithstanding any other restriction on reimbursement, a county shall adopt a fee schedule and
reimbursement methodology to establish a uniform reasonable level of reimbursement from the county's
emergency medical services fund for reimbursable services.
(f) For the purposes of submission and reimbursement of physician and surgeon claims, the administering
agency shall adopt and use the current version of the Physicians' Current Procedural Terminology, published by
the American Medical Association, or a similar procedural terminology reference.
(g) Each administering agency of a fund under this chapter shall make all reasonable efforts to notify physicians
and surgeons who provide, or are likely to provide, emergency services in the county as to the availability of the
fund and the process by which to submit a claim against the fund. The administering agency may satisfy this
requirement by sending materials that provide information about the fund and the process to submit a claim
against the fund to local medical societies, hospitals, emergency rooms, or other organizations, including
materials that are prepared to be posted in visible locations.
(Amended by Stats. 2005, Ch. 671, Sec. 3. Effective January 1, 2006.)
1797.98e. (a) It is the intent of the Legislature that a simplified, cost-efficient system of administration of this
chapter be developed so that the maximum amount of funds may be utilized to reimburse physicians and
surgeons and for other emergency medical services purposes. The administering agency shall select an
administering officer and shall establish procedures and time schedules for the submission and processing of
proposed reimbursement requests submitted by physicians and surgeons. The schedule shall provide for
disbursements of moneys in the Emergency Medical Services Fund on at least a quarterly basis to applicants who
have submitted accurate and complete data for payment. When the administering agency determines that claims
for payment for physician and surgeon services are of sufficient numbers and amounts that, if paid, the claims
would exceed the total amount of funds available for payment, the administering agency shall fairly prorate,
without preference, payments to each claimant at a level less than the maximum payment level. Each
administering agency may encumber sufficient funds during one fiscal year to reimburse claimants for losses
incurred during that fiscal year for which claims will not be received until after the fiscal year. The administering
agency may, as necessary, request records and documentation to support the amounts of reimbursement
requested by physicians and surgeons and the administering agency may review and audit the records for
accuracy. Reimbursements requested and reimbursements made that are not supported by records may be
denied to, and recouped from, physicians and surgeons. Physicians and surgeons found to submit requests for
reimbursement that are inaccurate or unsupported by records may be excluded from submitting future requests
for reimbursement. The administering officer shall not give preferential treatment to any facility, physician and
surgeon, or category of physician and surgeon and shall not engage in practices that constitute a conflict of
interest by favoring a facility or physician and surgeon with which the administering officer has an operational or
financial relationship. A hospital administrator of a hospital owned or operated by a county of a population of
250,000 or more as of January 1, 1991, or a person under the direct supervision of that person, shall not be the
administering officer. The board of supervisors of a county or any other county agency may serve as the
administering officer. The administering officer shall solicit input from physicians and surgeons and hospitals to
review payment distribution methodologies to ensure fair and timely payments. This requirement may be fulfilled
through the establishment of an advisory committee with representatives comprised of local physicians and
surgeons and hospital administrators. In order to reduce the county's administrative burden, the administering
officer may instead request an existing board, commission, or local medical society, or physicians and surgeons
and hospital administrators, representative of the local community, to provide input and make recommendations
on payment distribution methodologies.
(b) Each provider of health services that receives payment under this chapter shall keep and maintain records of
the services rendered, the person to whom rendered, the date, and any additional information the administering
agency may, by regulation, require, for a period of three years from the date the service was provided. The
administering agency shall not require any additional information from a physician and surgeon providing
emergency medical services that is not available in the patient record maintained by the entity listed in
subdivision (f) where the emergency medical services are provided, nor shall the administering agency require a
18-013 EXHIBIT B
Exhibit C
physician and surgeon to make eligibility determinations. Page 48 of 64
(c) During normal working hours, the administering agency may make any inspection and examination of a
hospital's or physician and surgeon's books and records needed to carry out this chapter. A provider who has
knowingly submitted a false request for reimbursement shall be guilty of civil fraud.
(d) Nothing in this chapter shall prevent a physician and surgeon from utilizing an agent who furnishes billing
and collection services to the physician and surgeon to submit claims or receive payment for claims.
(e) All payments from the fund pursuant to Section 1797.98c to physicians and surgeons shall be limited to
physicians and surgeons who, in person, provide onsite services in a clinical setting, including, but not limited to,
radiology and pathology settings.
(f) All payments from the fund shall be limited to claims for care rendered by physicians and surgeons to patients
who are initially medically screened, evaluated, treated, or stabilized in any of the following:
(1) A basic or comprehensive emergency department of a licensed general acute care hospital.
(2) A site that was approved by a county prior to January 1, 1990, as a paramedic receiving station for the
treatment of emergency patients.
(3) A standby emergency department that was in existence on January 1, 1989, in a hospital specified in Section
124840.
(4) For the 1991-92 fiscal year and each fiscal year thereafter, a facility which contracted prior to January 1,
1990, with the National Park Service to provide emergency medical services.
(5) A standby emergency room in existence on January 1, 2007, in a hospital located in Los Angeles County that
meets all of the following requirements:
(A) The requirements of subdivision (m) of Section 70413 and Sections 70415 and 70417 of Title 22 of the
California Code of Regulations.
(B) Reported at least 18,000 emergency department patient encounters to the Office of Statewide Health
Planning and Development in 2007 and continues to report at least 18,000 emergency department patient
encounters to the Office of Statewide Health Planning and Development in each year thereafter.
(C) A hospital with a standby emergency department meeting the requirements of this paragraph shall do both
of the following:
(i) Annually provide the State Department of Public Health and the local emergency medical services agency with
certification that it meets the requirements of subparagraph (A). The department shall confirm the hospital's
compliance with subparagraph (A).
(ii) Annually provide to the State Department of Public Health and the local emergency medical services agency
the emergency department patient encounters it reports to the Office of Statewide Health Planning and
Development to establish that it meets the requirement of subparagraph (13).
(g) Payments shall be made only for emergency medical services provided on the calendar day on which
emergency medical services are first provided and on the immediately following two calendar days.
(h) Notwithstanding subdivision (g), if it is necessary to transfer the patient to a second facility providing a
higher level of care for the treatment of the emergency condition, reimbursement shall be available for services
provided at the facility to which the patient was transferred on the calendar day of transfer and on the
immediately following two calendar days.
(i) Payment shall be made for medical screening examinations required by law to determine whether an
emergency condition exists, notwithstanding the determination after the examination that a medical emergency
does not exist. Payment shall not be denied solely because a patient was not admitted to an acute care facility.
Payment shall be made for services to an inpatient only when the inpatient has been admitted to a hospital from
an entity specified in subdivision (f).
(j) The administering agency shall compile a quarterly and yearend summary of reimbursements paid to facilities
and physicians and surgeons. The summary shall include, but shall not be limited to, the total number of claims
submitted by physicians and surgeons in aggregate from each facility and the amount paid to each physician and
surgeon. The administering agency shall provide copies of the summary and forms and instructions relating to
making claims for reimbursement to the public, and may charge a fee not to exceed the reasonable costs of
duplication.
18-013 EXHIBIT B
Exhibit C
(k) Each county shall establish an equitable and efficient mechanism for resolving disputes relatinaggToc pa ms for
reimbursements from the fund. The mechanism shall include a requirement that disputes be submitted either to
binding arbitration conducted pursuant to arbitration procedures set forth in Chapter 3 (commencing with
Section 1282) and Chapter 4 (commencing with Section 1285) of Part 3 of Title 9 of the Code of Civil Procedure,
or to a local medical society for resolution by neutral parties.
(1) Physicians and surgeons shall be eligible to receive payment for patient care services provided by, or in
conjunction with, a properly credentialed nurse practitioner or physician's assistant for care rendered under the
direct supervision of a physician and surgeon who is present in the facility where the patient is being treated and
who is available for immediate consultation. Payment shall be limited to those claims that are substantiated by a
medical record and that have been reviewed and countersigned by the supervising physician and surgeon in
accordance with regulations established for the supervision of nurse practitioners and physician assistants in
California.
(Amended by Stats. 2008, Ch. 288, Sec. 2. Effective January 1, 2009.)
1797.98f. Notwithstanding any other provision of this chapter, an emergency physician and surgeon, or an
emergency physician group, with a gross billings arrangement with a hospital shall be entitled to receive
reimbursement from the Emergency Medical Services Fund for services provided in that hospital, if all of the
following conditions are met:
(a) The services are provided in a basic or comprehensive general acute care hospital emergency department,
or in a standby emergency department in a small and rural hospital as defined in Section 124840.
(b) The physician and surgeon is not an employee of the hospital.
(c) All provisions of Section 1797.98c are satisfied, except that payment to the emergency physician and
surgeon, or an emergency physician group, by a hospital pursuant to a gross billings arrangement shall not be
interpreted to mean that payment for a patient is made by a responsible third party.
(d) Reimbursement from the Emergency Medical Services Fund is sought by the hospital or the hospital's
designee, as the billing and collection agent for the emergency physician and surgeon, or an emergency
physician group.
For purposes of this section, a "gross billings arrangement" is an arrangement whereby a hospital serves as the
billing and collection agent for the emergency physician and surgeon, or an emergency physician group, and
pays the emergency physician and surgeon, or emergency physician group, a percentage of the emergency
physician and surgeon's or group's gross billings for all patients.
(Amended by Stats. 1998, Ch. 1016, Sec. 3. Effective January 1, 1999.)
1797.989. The moneys contained in an Emergency Medical Services Fund, other than moneys contained in a
Physician Services Account within the fund pursuant to Section 16952 of the Welfare and Institutions Code, shall
not be subject to Article 3.5 (commencing with Section 16951) of Chapter 5 of Part 4.7 of Division 9 of the
Welfare and Institutions Code.
(Added by Stats. 1991, Ch. 1169, Sec. 4.)
made
Exhibit C
Page 50 of 64
COUNTY OF FRESNO
ti G0��
0 s 0
�rRB`Wl
REQUEST FOR QUOTATION
NUMBER: 13-013
FISCAL INTERMEDIARY FOR THE EMERGENCY
MEDICAL SERVICES FUND
Issue Date: October 13, 2017
Closing Date: NOVEMBER 15, 2017 AT 2:00 P.M.
All Questions and Quotations must be electronically submitted on the Bid Page on Public Purchase.
For assistance, contact Darren Howard at Phone (559) 600-7110.
BIDDER TO COMPLETE
Undersigned agrees to furnish the commodity or service stipulated in the attached response at the prices and terms stated in this RFQ.
Bid must be signed and dated by an authorized officer or employee.
Except as noted on individual items,the following will apply to all items in the Quotation Schedule:
• A cash discount of 0 % days will apply.County does not accept terms less than 15 days.
Advanced Medical Management, Inc.
COMPANY
5000 Airport Plaza Drive, Suite 150
ADDRESS
Long Beach CA 90815
CITY STATE ZIP CODE
5 562-766-2006( ) 62-76P-2000� ( ) ppew@amm.cc
TELEPHONE KUUfJIBE FACSIMILE NUMBER E-MAIL ADDRESS
SIGNATURE If
Kathryn Hegstrom President
PRINT NAME TITLE
Purchasing Use:DH:st ORGIRequisition:56208799/5621800305
G:1PubI1c\RFQ1FY 2017-18118-013 Fiscal Intermediary for the Emergency Medical Services Fund118-013 Fiscal Intermediary for the Emergency Medical
Services Fund.doc
Exhibit C
Page 51 of 64
COUNTY OF FRESNO
ADDENDUM NUMBER: ONE (1 )
RFQ NUMBER: 18-013
FISCAL INTERMEDIARY FOR THE EMERGENCY
MEDICAL SERVICES FUND
Issue Date: November 15, 2017
CLOSING DATE: NOVEMBER 22, 2017 AT 2:00 P.M.
Submit all Questions and Quotations on the Bid Page at Public Purchase.
For assistance contact Darren Howard at(559) 600-7110.
NOTE THE FOLLOWING ADDITIONS, DELETIONS AND/OR CHANGES TO THE REQUIREMENTS OF
REQUEST FOR QUOTATION NUMBER: 18-013 AND INCLUDE THEM IN YOUR RESPONSE. PLEASE SIGN
AND RETURN THIS ADDENDUM WITH YOUR QUOTATION.
➢ RFQ 18-013 closing date has been postponed. The revised closing date is November 22, 2017.
ACKNOWLEDGMENT OF ADDENDUM NUMBER ONE (_1)TO RFQ 18-013
COMPANY NAME: Adyanceq Medical Management, Inc.
....... m„... (PRINT)
SIGNATURE: _- ,' _.. "0 °. ,..
NAME &TITLE: Kathryn Hegstron, President
(PRINT)
Purchasing Use:DH:st ORG/Requisition:56208799/5621800305
G:\PUBLIC\RFQ\FY 2017-18\18-013 FISCAL INTERMEDIARY FOR THE EMERGENCY MEDICAL SERVICES FUND\18-013
ADDENDUM 1.DOC
Exhibit C
Page 52 of 64
Advanced Medical Management, Inc. has demonstrated its ability to perform all of the services
requested by Fresno County. Currently AMM performs contracted services for the Orange
County Health Care Agency ("OCHCA")by functioning as the Fiscal Intermediary for the past
eleven program years (2006-2017) for the Emergency Medical Services Fund Program, Public
Health Program and Correctional Health Services Program and for the past three years for the
Medical Safety Net Program. AMM was also the Fiscal Intermediary for the very large Medical
Services Initiative Program for eight years (2006-2013). During that time,AMM adapted to a
wide array of significant program changes that occurred as well as the quadrupling of the MSI
enrollment and the corresponding increases in volume of work. AMM has not only kept pace
with those changes and increases, but has facilitated and assisted the Program in analyzing the
options and recommending those changes. AMM has worked closely with all other OCHCA
vendors including CCS,NetChemistry, MedImpact, Propharma, RxAmerica, CareMark, Quest
Laboratories and DHS in developing efficient data exchange, cooperative relationships and
enhanced procedures. AMM has adapted to multiple changes in Program and vendor staff
positions while maintaining consistency in technical and administrative contacts internally.
AMM has responded quickly and accurately to unanticipated funding and payment course
corrections and has in many cases been the vehicle of communication for the Program of those
changes to the affected providers. AMM has provided advice and technical experience for the
implementation of provider incentives, capitation methodologies, mandatory referral
authorizations and pharmacy protocols. AMM successfully went through re-negotiation and/or
RFP with all of these programs multiple times and AMM interacts with each of these programs
independently as all have different program personnel and unique processing requirements.
AMM has developed relationships of trust with all OCHCA medical providers and our existing
phone numbers, websites, FTP sites, staff contacts and procedures are familiar to everyone.
AMM has the management information software necessary to keep all of the disparate, vendor
specific OCHCA information managed in one unified and cohesive system. EZ-Cap is a well-
established managed care tool designed specifically to integrate patient,provider, referral
authorization, claims, case management and customer service data. In all of the many and varied
management situations described above, AMM has successfully programmed and processed
Exhibit C
Page 53 of 64
hundreds of thousands of data elements together such that each client is accurately and uniquely
managed.
Advanced Medical Management has also performed the services described in this Fiscal
Intermediary Services RFP for many years and to many non-government agency clients
including Independent Physician Associations (IPA) and Hospitals. For our these clients we
provide many additional services including: eligibility processing, claims receipt, adjudication
and payment services, fund management, financial reporting, referral authorization request
processing, inpatient and outpatient utilization management and case management services.
AMM has been a full service Management Services Organization from 1993 until the present.
We have performed these services concurrently to over 100,000 managed care patients covered
by all of the major health plans in Southern California—past and present—including Aetna,
Anthem Blue Cross, Blue Shield, CalOPTIMA, CareAmerica, Central Health Plan, Cigna,
Community Health Plan of Los Angeles, Easy Choice, FHP, Health Net, LA Care, Maxicare,
MDCare, MetLife, Molina, PacifiCare, SecureHorizons, SCAN, TakeCare, Tower,Universal,
UHP, United Healthcare. We have been audited by those health plans constantly with thousands
of referral authorizations (approved and denied), and tens of thousands of claims (paid and
denied)reviewed and scored. We have also been audited by healthcare consultants and certified
public accounts without sanction or significant negative findings. We have performed these
services for all major product lines including Commercial, Medi-Cal, Covered California,
Healthy Families, Point of Service, Medicare and Cal MediConnect and all of the differing and
changing regulations and standards that have been enforced over twenty-two years. We have
performed those services in Orange, Los Angeles, Riverside, San Bernardino, Santa Clara and
Imperial Counties. We have performed those services in English, Spanish, Korean and
Vietnamese languages. We have performed those services with no change to AMM's
ownership, upper management personnel, or business strategy. We are confident that no other
applicant proposing to provide these services to the Fresno County can match the variety of
circumstances for which AMM has successfully provided these services.
Exhibit C
Page 54 of 64
AMM is also the Third Party Administrator for the County Medical Services Program (CMSP)
which is a consortium of 35 rural counties in California providing the exact same services as the
OCHCA Medical Safety Net Program. AMM transitioned management of this program from
Anthem Blue Cross effective April 1, 2015.
AMM has been a user of EZ-Cap Benefits Management software since 1995 (22 years). EZ-Cap
is a mainstream benefits management software that is in use by health plans, IPAs, and other
managed care entities nationally. AMM uses the latest 6.5 release of the software which is
written in .NET and has robust user security and role-based user profiles. Each AMM User has a
unique identification number and is assigned to client databases and modules based on their need
to access data. EZ-Cap has an Audit Trail that records the User, Date and Time any claim,
authorization, eligibility or other support table record was changed. AMM actively uses this
feature to control and manage the way claims are queued for processing. At any time a user or
manager can see when a claim was created, modified, adjudicated,paid or denied and by what
user ID.
EZ-Cap is programmed with unlimited Provider Fee Sets, Division of Financial Responsibility
Sets, Benefit Sets and additional technical tables that allow for automatic claims pricing
according to definable rules. Providers with special contracts are programmed with their specific
codes payable at the agreed upon rates but only under the conditions specified in the contract.
AMM maintains hundreds of such provider-specific rules as well as all of the program-specific
rules that control pricing.
AMM also uses the EZ-Cap EDI application which contains standard maps for all HIPAA X12
standard(501015010) file formats as well as EZ-Cap Proprietary Formats (EPFs) for use
submitting authorizations, claims, membership, and paid claims from multiple Trading Partners.
AMM's network structure allows for the exchange of information between our organization,
providers and health plans without compromising EZ-Cap system security. Within the EZ-Cap
Configuration and Users/Security modules, AMM creates separate user profiles to enable or
disable functionality and viewing of data depending on the user group. AMM network security
requires periodic password changes and locks workstations after 5 minutes of un-use.
Exhibit C
Page 55 of 64
AMM conducts annual HIPAA training of all our employees as well as new hire training and
provide written policies and instructions to employees for handling transactions in
compliance with the law. AMM has secure internet reporting portals for transmitting
information, data and reports to clients and uses two methods for transmitting secure email.
AMM is a Business Associate to all of our contracted clients who are Covered Entities and
we have signed agreements in place to ensure that AMM policies and procedures are
consistent with and maintain the compliance of our clients.
Exhibit C
Page 56 of 64
VENDOR MUST COMPLETE AND RETURN WITH REQUEST FOR QUOTATION.
Firm: Advanced Medical Management, Inc.
REFERENCE LIST
Provide a list of at least five (5) customers for whom you have recently provided similar
products/services. Be sure to include all requested information.
Emergency Medical Services Fund (EMSF
Reference Name: Con•ct: Shelly Vrungos, Program Mgr.
Address: 405 W. 5th Street, 7th Floor
City: Santa Ana state: CA zip: 92701
Phone No.: ) 714-834-6249 Date: July 1, 2006 - present
Service Provided: Fiscal Intermediary Services including claims adjudication and payment
fund management, claims recovery, reporting, electronic data interchange, consultation
RefereneeName: Medical Saftey Net Program (MSN)Contact Cynthia Aguirre, Admin Mqr.
Address: 405 W. 5th Street
city: Santa Ana state: CA zip: 92701
Phone No.: ( ) 714-834-2404 Date: Jan 1, 2014 - Present
Service Provided: Fiscal Intermediary Services, including claims adjudication and payment
fund management, claims recovery, reporting, electronic data interchange, consultation
Reference Name: Community Care IPA contact: Yvonne Bell, MBA, CEO
Address: 1166 K Street
city: Brawley state: CA zip: 92227
Phone No.: ) 760-344-9951 Date: October 4, 2014 - Present
Service Provided: Management Services including claims adjudication and payment,
Utilization Mgt., Care Mgt., Capitation, Finance, Contracting, Eligibility, claims recovery
physician network and health plan contracting, reporting, analysis, marketing
ReferenceNane: MSN and EMSF Programs Contact: Melissa Tober-Beers
Address: 405 W. 5th Street Manager, Strategic Projects
eiry. Santa Ana state: CA zip: 92701
Phone No.: ( ) 714-834-5891 Date: July 1, 2016 - Present
Service Provided: Fiscal Intermediary Services, including claims adjudication and payment
fund management, claims recovery, reporting, electronic data interchange, consultation
physician network and health plan contracting, reporting, analysis, marketing
Reference Name: Seoul Medical Group, Inc. contact. Min Young Cha, M.D., CEO
Address: 520 S. Virgil Avenue, #507
city: Los Angeles state: CA zip: 90020
Phone No.: ( ) 213-480-7770 Date: January 1, 2012 - Present
Service Provided: Management Services including claims adjudication and payment,
Utilization Mgt., Care Mgt., Capitation, Finance, Contracting, Eligibility, claims recovery
physician network and health plan contracting, reporting, analysis, marketing
Failure to provide a list of at least five (5) customers may be cause for rejection of this RFQ.
Exhibit C
Page 57 of 64
VENDOR MUST COMPLETE AND RETURN WITH REQUEST FOR QUOTATION.
Firm: Advanced Medical Management, Inc.
REFERENCE LIST
Provide a list of at least five (5) customers for whom you have recently provided similar
products/services. Be sure to include all requested information.
Reference Narne: MediChoice IPA, Inc. Contact: Hung Nguyen, M.D., MBA, CEO
Address: 10900 Westminster Avenue, Suite 3
city: Garden Grove state: CA zip: 92843
Phone No.: ( ) 714-725-5162 Date: May 1, 2013 - Present
Service Provided: Management Services including claims adjudication and payment,
Utilization Mgt., Care Mgt., Capitation, Finance, Contracting, Eligibility, claims recovery
physician network and health plan contracting, reporting, analysis, marketing
Reference Name: Hollywood Presbyterian Med. Ctr. contact: Hank Lee, Director of Managed Care
Address: 1300 N. Vermont Avenue
city: Los Angeles state: CA zip: 90027
Phone No.: ( ) 213-487-3211 Date: December 1, 2014 - Present
Service Provided: Institutional claims adjudication and payment, risk pool financials,
eligibility, interface with IPA and Health Plans, provider contracting
Reference Name: Contact:
Address:
City: State: Zip:
Phone No.: ( ) Date:
Service Provided:
Reference Name: Contact:
Address:
City: State: Zip:
Phone No.: ( ) Date:
Service Provided:
Reference Name: Contact:
Address:
City: State: Zip:
Phone No.: ( ) Date:
Service Provided:
Failure to provide a list of at least five (5) customers may be cause for rejection of this RFQ.
Exhibit C
Page 58 of 64
QUOTATION SCHEDULE
Propose your most competitive Average Cost per Claim for the contract period stated below based on the
equation provided. If awarded a contract, proposed rates will be finalized during contract negotiations.
A claim is defined as any request for payment of a medical service that the FI has to adjudicate (whether it is
approved, denied, incomplete, etc.). The process for one claim includes all administrative and customer
service transactions to process the entire claim, including review, investigation, adjustment (if necessary),
and remittance or denial of the claim. The proposed rate(s) must include all labor, materials, equipment,
insurance coverage, permits, licenses, preparation of all faxed and/or mailed/delivered reports, and all other
fees to provide the services specified in this solicitation; and include the rationale and methodology to justify
the proposed rate(s).
Approximate number of claims processed over 12 month period: 15,000
Total Negotiated Rate: $ (if proposed) $25,000 implementation fee in Year 1 to program AMM systems
Total Fee-for-Service: $ 75,000 (if proposed, include all costs you are proposing on a fee-for
service basis. Multiply your per claim rate by the estimated 15,000 claims per year)
Total Other Cost: $200/hour (if proposed)
Please explain "Other Ad hoc reporting, consulting or other administrative services as requested.
Average Cost per Claim*: $6.67 in Year 1, $5/claim in subsequent years
*Average Cost per Claim = the Total of the values entered for Total Negotiated Rate, Total Fee-for-Service,
and Total Other divided by 15,000.
Reimbursement was developed by first assessing the staffing needs associated with the
various functions required to service the contract. AMM is an established Fiscal
Intermediary and Management Services Organization so all of the applicable departments
and internal processes already exist. AMM has evolved its infrastructure to be scalable
and can easily accommodate changing business realities. This scalability is further
enhanced by our focus on utilizing technology to create a more efficient work
environment. We utilized staffing ratios related to claims volume, departmental oversight
for each department, projected the time involvement of multiple MIS team members,
allocated key senior management team members, determined new equipment needs, and
allocated our fixed overhead according to the overall volume associated with the contract.
We believe in investing in our personnel and providing them with the technology-based
tools to enhance their productivity and overall efficiencies. Our Senior Management team
takes an active role with each Client and is an integral participant of the day-to-day
operations. The budget developed to service Emergency Medical Services Fund
contemplated both claims and administrative services identified to run the Programs
successfully.
Exhibit C
Page 59 of 64
COMPLY/NOT COMPLY
Compliance and understanding of the specification is to be noted by marking "COMPLY" on the
line provided to the right of the specification. Non-compliance is to be indicated by marking
"NOT COMPLY" on the line. All non-compliant items must be accompanied by a detailed
statement explaining why they fail to meet the stated specification or requirement.
BIDDER TO COMPLETE THE FOLLOWING: COMPLY/
NOT COMPLY
1. Fully adjudicate claims received from authorized providers within forty-five (45)
business days after receipt of correctly submitted claims or invoices, and
supporting documentation (when applicable), at the rate specified by the County,
and make other required payments COMPLY
2. Receive, maintain, collect, and account for funds. COMPLY
3. Review all claims to ensure County responsibility is verified. Ensure that the
County is the payor of last resort. COMPLY
4. Apply industry standard procedures for claims review. Request supporting claims
documentation from authorized providers when appropriate. Deny all claims that do
not meet the conditions and requirements for claims submission, processing, and
reimbursement.
COMPLY
5. The selected bidder shall submit their procedures for claims review to the County
within thirty(30) calendar days of the start of the executed contract.
COMPLY
6. Receive, compile, preserve, and report information and data to the County on a
schedule to be agreed upon between the County and the selected bidder. Reports
shall be provided as a Microsoft Excel spreadsheet in a format mutually agreed
upon by all parties, and/or shall be available to the County via a secure web-based
reporting tool/portal. General types of reports for all programs shall include, but not
be limited to:
a. Claims Detail Report and Claims Summary Report
b. Claims Status Report and Claims Status Summary Report
C. Fund Reconciliation Report
d. Account Statement
e. Service Utilization Report
f. Recovery Account Status Report
g. Denial Report
h. Ad-hoc Reports COMPLY
7. Use a Health Insurance Portability and Accountability Act (HIPAA) compliant
automated claims system, and adhere to all Protected Health Information (PHI)
and Personal Identifiable Information (PII) regulations.
COMPLY
8. Implement encryption security measures for authorized providers to submit
electronic claims data; provide training to providers on those security measures,
and ensure those security measures are adhered to.
COMPLY
Exhibit C
Page 60 of 64
BIDDER TO COMPLETE THE FOLLOWING: COMPLY/
NOT COMPLY
9. Designate a primary and alternate contact persons dedicated to facilitating
communication with authorized providers submitting claims, County staff, and
authorized patient representatives, and ensure all parties have the relevant phone
number and email address. COMPLY
10. Retain and maintain all records relating to patient care for a minimum of seven (7)
years. COMPLY
11. Review and pay claims based on the date services are provided; and in
accordance with the specific funding source requirements, i.e., claims must be for
emergency services and/or care provided by a physician in a hospital emergency
room setting, and services rendered are within the appropriate time limits. COMPLY
12. Authorized providers shall have up to four(4) months of the date of service quarter
ending date to submit claims for services; however, they cannot bill for services
prior to ninety(90) days following the date of service as they must be able to
demonstrate, if audited, that they have made three (3) attempts to collect from the
patient and have been unsuccessful in that collection effort. COMPLY
13. Pay claims up to the maximum amount an authorized provider may be paid, as
specified by law. Authorized providers are currently paid at a percentage of
Resource Base Relative Value Scale (RBRVS)determined by the County, or 50%
of allowable charges, whichever is less. The maximum payment limits apply at
Final Settlement.
COMPLY
14. Request additional funds if the amount of claims received exceeds the amount of
funds initially made available.
COMPLY
15. Conduct the Final Settlement process within sixty(60) days following the end of the
contract year if funds remain in the Account, to distribute the balance of the funds
proportionate to the claims paid during the contract period.
COMPLY
16. Maintain a physician registration system in accordance with county policies, and
only reimburse physicians that are registered. The PSA Program will also provide
"Conditions of Participation" (COPS)that registered providers must agree to in
order to participate in the EMS Program, and certain of these COPs may require
specific acceptance/agreement by the provider before moving on in the registration
process. COMPLY
17. Provide directly, or through a County-approved subcontract arrangement, third-
party recovery services to actively pursue reimbursement of claims paid from the
PSA fund that are later determined to be eligible for Medi-Cal, other insurance or
third-party payment.
COMPLY
Exhibit C
Page 61 of 64
BIDDER TO COMPLETE THE FOLLOWING: COMPLY/
NOT COMPLY
18. Organization possesses a minimum of five (5) years of experience and expertise
performing services for a California County similar in complexity and scope to the
requested services. COMPLY
19. Organization agrees to entertain, and accept if feasible, proposals by the County to
add services similar in complexity and scope to the eventual agreement in the
future.
COMPLY
Exhibit C
Page 62 of 64
Quotation No. 18-013 Page 12
BIDDER TO COMPLETE THE FOLLOWING:
PARTICIPATION
The County of Fresno is a member of the Central Valley Purchasing Group. This group consists of Fresno,
Kern, Kings, and Tulare Counties and all governmental, tax supported agencies within these counties.
Whenever possible, these and other tax supported agencies co-op (piggyback) on contracts put in place by
one of the other agencies.
Any agency choosing to avail itself of this opportunity, will make purchases in their own name, make
payment directly to the contractor, be liable to the contractor and vice versa, per the terms of the original
contract, all the while holding the County of Fresno harmless. If awarded this contract, please indicate
whether you would extend the same terms and conditions to all tax supported agencies within this group as
you are proposing to extend to Fresno County.
Yes, we will extend contract terms and conditions to all qualified agencies within the Central Valley
Purchasing Group and other tax supported agencies.
No, we will not extend cont act terms to any agency other than the County of Fresno.
is
(Authorize !Signature)
President
Title
G:IPUBLICIRFQIFY 2017-18118-013 FISCAL INTERMEDIARY FOR THE EMERGENCY MEDICAL SERVICES FUND118-013 FISCAL INTERMEDIARY FOR
THE EMERGENCY MEDICAL SERVICES FUND.DOC
Exhibit C
Page 63 of 64
BIDDER TO COMPLETE:
SUBCONTRACTORS:
List all subcontractors that would perform work in excess of one/half of one percent of the total amount of
your bid, and state general type of work such subcontractor would be performing. The primary contractor is
not relieved of any responsibility by virtue of using a subcontractor:
WCEDI-BPO 4250 Veterans Memorial Hwy., Suite 301, Holbrook, NY 11741
This subcontractor captures scanned claim images from AMM via secure FTP and
converts into electronic data that is returned to AMM via secure FTP.
Exhibit C
Page 64 of 64
CHECK LIST
This Checklist is provided to assist the vendors in the preparation of their bid response. Included in this list,
are important requirements and is the responsibility of the bidder to submit with the bid package in order to
make the bid compliant. Because this checklist is just a guideline, the bidder must read and comply with the
bid in its entirety.
Check off each of the following:
1. X The Request for Quotation (RFQ) has been signed and completed.
2. X Addenda, if any, have been signed and included in the bid package.
3. X The completed Reference List as provided with this RFQ.
4. X The Quotation Schedule as provided with this RFQ has been completed, price reviewed for
accuracy and any corrections initialed.
5. X Indicate all of bidder exceptions to the County's requirements, conditions and specifications
as stated within this RFQ.
6. X The Participation page as provided within this RFQ has been signed and included
7. X Bidder to Complete page as provided with this RFQ.
8. X Return checklist with RFQ response.
9. X Completed RFQ in pdf format, electronically submitted to the Bid Page on Public
Purchase.