HomeMy WebLinkAboutAgreement A-15-130 with Sante Health.pdfAGT. # 15-130
AGREEMENT TO ADMINISTER ASSEMBLY BILL 2731
REIMBURSEME-NT FUNl>
This Agreement is made and entered into this 1'fb· day of ~11.\}tl.h ..... • 2015, by
and between the COUNTY OF FRESNO, a Political Subdivision of the State of California
(''COUNTY") and SANTE llEALTll SYSTEM. d.b.a. ADVANTEK HENEFIT
ADMINISTRATORS ("ADMINISTRATOR"), a California corporation. COUNTY and
ADMINTSTRA TOR are referred to herein, collectively, as "'Parties", or "Party'' individually.
\V I T N E S S E T H:
Whereas, Assembly Bill ("A.B.") 273l was approved by the State of California
Governor, Edmond "Jerry" Brown, on September 28, 2014. w·hich provides COUNTY may
extend the deadline on its maintenance of efiort requirement from the Transportation Inveslment
Fund for the 2009" 10 fiscal year until June 30, 2020, if COUNTY expends no 1ess than $5.5
million to provide specialty medical services in coJ1junction with federally funded clinics to
indigent individuals, including hut not limited to. those individual who are ineligible for full-
scope Medi-Cal; and
Whereas, on November 4, 2014, the COUNTY's Board of Supervisors ("Board")
directed COUNTY statT to develop an A.B. 2731 reimbursement fund .f(>r the provision of
specialty medical services for indigent residents ("Beneficiaries" or "Beneficiary") that do not
quality for other health care options (e.g., full scope Medi-Cal, MlSP) and to return to the Board
upon completing the development of the A.B. 2731 reimbursement fund; and
Whereas, ADMTNISTRATOR desires to administer the A.B. 2731 reimbursement fund
by selecting Beneficiaries from referrals it obtains from certain federally funded clinics and/or
emergency medical hospitals that coordinate with federally funded clinics (see Reterral List
attached hereto as Exhibit A and inc<1rporated by this reference herein) who meet certain
eligibility criteria and allocate the A.B. 2731 reimbursement fund on a 1irst come first serve ha..:;is
to certain medical providers (see Medical Provider List attached hereto as Exhibit B and
incorporated herein by this reference) who perform non"emergency or urgent specialty care
services to Beneficiaries.
Nowt therefore, COUNTY and ADMINISTRATOR, in consideration of the covenants,
agreements, and promises hereinafter set lhtih, agree as follmvs:
SECTION 1-RESPONSIBILITIES OF ADMlNlSTRA 1'0R
Jn consideration for the compen&ation set forth in Section 2, herein, ADMI~ISTRATOR shall be
responsible to:
l.l Seled Beneficiaries From Referrals: ADMlNISTRATOR shall be responsible to select
Beneticiaries from referrals exclusively provided by certain federally funded clinics and/or
emergency hospitals that coordinate with the federally funded clinics listed in Exhibit A,
attached hereto, in accordance \-Vith the below provisions.
1.1.1 Referral Form: ADMINISTRATOR shall administer the A.B. 2731
reimbursement fund by accepting the Specialty Care Referral Form for A.B. 2731
(2014) Reimbursement Funding ("Referral Form") (attached hereto as Exhibit
"C" and incorporated herein by this reference) from the federally funded clinics
and/or emergency hospitals who coordinate with the federally funded clinics
listed in Exhibit A, attached hereto.
1.1.1.1 ADMINISTRATOR shall not process payment from any other
method or form of referral with respect to the A.B. 2731
reimbursement fund.
1.1.2 Referral Form Must Be Complete and Accurate: ADMINISTRATOR shall
screen each Referral Form to ensure they are accurate and complete prior to
processing for payment.
1.1.2.1 An accurate and complete Referral Form means it contains the
following (note: the numbers below reflect the numbers identified in
the boxes ofthe Referral Form for ease of reference):
1. Date of the request
2. Date last seen by requesting physician
3. Beneficiary's first and last name, date of birth, age, and gender
4. Beneficiary's address
• If the Beneficiary does not have an address because he/she
is homeless, this portion of the Referral Form must be
marked "none" or "homeless" -a blank would be
considered an incomplete Referral Form to be denied by
ADMINISTRATOR
5. Either: (a) "yes" marked to the beneficiary having restricted
Medi-Cal and the MEDS Aid Code number and the BIC/CIN
number; or (b) "no" marked to the Beneficiary having restricted
Medi-Cal with the MEDS Aid Code and BIC/CIN left blank and a
"yes" marked to the beneficiary having a pending Medi-Cal
application with the Medi-Cal application date
• If "yes" is marked to having restricted Medi-Cal, but there
is no MEDS Aid Code or no BIC/CIN, or neither are listed,
ADMINISTRATOR shall deny the Referral Form
• If "no" is marked to the Beneficiary having restricted
Medi-Cal with the MEDS Aid Code and BIC/CIN left
blank but a "no" (instead of a "yes") is marked to the
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Beneficiary having a pending Medi-Cal application,
ADMINISTRATOR shall deny the Referral Form
6. Full name of requesting physician, which may be either the
emergency care or the primary care physician; tax identification
number of the federally funded clinic or emergency hospital on
the referral list in Exhibit A, attached hereto; and name of the
federally funded clinic/emergency hospital, which must be listed
on Exhibit A
• If the name of clinic/hospital and location provided on the
Referral Form is not on the referral list in Exhibit A,
attached hereto, the referral shall be denied by
ADMINISTRATOR
7. Contact person at the federally funded clinic/emergency hospital
listed; telephone and facsimile of federally funded
clinic/emergency hospital listed; name of the primary care
physician must be filled in if the requesting physician (e.g., the
emergency physician) is not the primary care physician
• ADMINISTRATOR need not deny the Referral Form if
there is no name of the primary care physician
8. The address of the federally funded clinic or emergency hospital
listed
• If the address listed does not match up with a location of a
federally funded clinic or emergency hospital listed in
Exhibit A, ADMINISTRATOR must deny the Referral
Form
9. The type of referral requested must be marked, and the CPT
code/s shall be filled in
• If a note is written on the Referral Form for a different
type of specialty care service not within the scope of the
A.B. 2731 reimbursement funding, as provided in Exhibit
D, attached hereto and incorporated by reference herein,
the referral shall be denied by ADMINISTRATOR
10. Medical Diagnosis, ICD-9 Code, and Date of Onset must be filled
in by the requesting physician
11. Referring physician comments and clinical data is optional and
ADMINISTRATOR shall not automatically deny the referral if
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the remaining portions of the Referral Form are complete and
accurate
12. Beneficiary must mark his/her language that he/she speaks or fill
in his/her language in the "other" box
13. Beneficiary must fill in his/her full name, sign and date the
Applicant's Attestation in his/her appropriate language of Spanish
or English
• If Beneficiary indicates he/she speaks a different language
than English/Spanish, ADMINISTRATOR shall notify the
COUNTY's Department of Public Health Director or
his/her designee as soon as possible so that the COUNTY
may provide the Beneficiary with an attestation translated
to his/her language for signature
• Upon completion of the attestation in the appropriate
language, the ADMINISTRATOR may move forward with
processing the Referral Form
14. The Beneficiary's requesting physician must fill in his/her full
name, sign and date the appropriate Physician's Attestation for
primary or emergency
1.1.3 Denial of Incomplete and Inaccurate Referral Forms: ADMINISTRATOR
shall deny any inaccurate or incomplete Referral Forms in writing, and provide
that denial to the clinic/hospital, requesting physician, primary care physician (if
different), and applicant. COUNTY shall have no obligation to compensate
ADMNISTRA TOR for such referral clairn/s if the Referral Form is not accurate
and complete as provided in Section 1.1.2.
1.1.4 Preliminary Assurance If Referral Form Is Marked "Yes" To Pending Medi-
Cal Application: ADMINISTRATOR is required to obtain a preliminary
assurance in writing from COUNTY's Director of Department of Public Health,
or his/her designee, if a Referral Form is marked "yes" to "Medi-Cal application
pending". Upon ADMINISTRATOR's receipt of the written preliminary
assurance from the COUNTY's Director of Department of Public Health, or
his/her designee, it may proceed with processing payment as provided herein.
1.1.4.1 ADMINISTRATOR is not required to obtain the COUNTY's preliminary
assurance on Referral Forms that are marked "Yes" to Restricted Medi-
Cal and are accurate and complete in accordance to Section 1.1.2.1, prior
to processing payment as set forth in Section 2. However,
ADMINISTRATOR may consult with COUNTY's Director of
Department of Public Health, or his/her designee, on an as needed basis
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should ADMINISTRATOR have questions pertaining to whether a
Referral Form is complete and accurate.
1.2 Process Referral Claims Only For Claims Within The Scope of Services:
ADMINISTRATOR shall only process referral claims that request reimbursement from the
A.B. 2731 reimbursement funding scope of services, which are listed in Exhibit D.
COUNTY shall not be responsible for providing payment for those referral claims that are
not within the scope of services listed in Exhibit D, and reserves the right to deny payment
on such clairn!s under Section 2.1 below.
1.2.1 Exclusions From The Scope of Services: ADMINISTRATOR shall not process
referral claims and COUNTY shall not be responsible for providing payment for
the following services:
Medical Services Provided Outside the Fresno Metropolitan Area
Specialty Medical Services not referred by a clinic or hospital listed in
Exhibit A
Specialty Medical Services not provided by the medical providers listed
in Exhibit B
Any service not covered by Medi-Cal
Primary Care
Emergency Care (i.e., a medical condition manifesting itself by acute
symptoms of sufficient severity, including severe pain, such that the
absence of immediate medical treatment could reasonably be expected
to result in placing the patient's health in serious jeopardy, serious
impairment to bodily functions, and/or serious dysfunction to any
bodily organ or part)
Pre-natal/pregnancy related services (pre-natal care, labor, delivery, up
to 60 days post-partum care and family planning)
Non-Emergency Dental, Vision, and Behavioral Health Care Services
Organ Transplants
Chiropractic Services and Acupuncture Services
Fertility Treatments and Reversals, Family Planning Services, and
Impotency Services
Abortion Services
Breast and Cervical Cancer Treatment
Skilled Nursing Facilities and Long-Term Care Facilities
Methadone Maintenance and Drug and Alcohol Treatment
Allery Testing, Injections, or Treatment
Sexual Reassignment Surgery
Gastric Bypass or Other Weight Loss Surgery and Weight Loss/Control
Services
Non-Emergency Follow-Up Care Provided in an Emergency Room
Non-Emergency Hepatitis C Treatment
Minor Consent Services (substance abuse treatment 12 or older, mental
health services 12 or older, family planning/pregnancy-related services,
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sexually transmitted diseases 12 or older, and sexual assault/rape
treatment)
Child Health and Disability Prevention (i.e., regular pediatric primary
care, immunizations, nutrition and lead screening, vision, hearing and
lab tests, dental, outreach and educational services, referrals for further
diagnosis/treatment, and temporary full scope Medi-Cal benefits)
Refugee Medical Assistance or Entrant Medical Assistance
Emergency Disaster Relief
MISP Benefits
Any service that a FQHC or RHC is mandated to provide by Federal
law (42 U.S.C. §254b(b)) (e.g. primary care, immunizations,
communicable disease screening, cancer screening, diagnostic,
laboratory, radiology services, eye, ear and dental screenings for
children, and pharmaceutical services)
1.3 Refer Beneficiaries To Medical Providers: ADMINISTRATOR shall assist the federally
funded clinics and/or emergency hospitals listed in Exhibit A, attached hereto, on an as
needed basis to find the appropriate medical providers listed in Exhibit B, attached hereto, to
provide non-emergency specialty care services within the scope of services listed in Exhibit
D, attached hereto, to Beneficiaries.
SECTION II-COMPENSATION
In exchange for performing the responsibilities listed in Section 1, herein, ADMINISTRATOR
shall obtain reimbursement according to the provisions below.
2.1 Reimbursement for Third Party Administration Fees and Specialty Professional
Medical Services:
Specialty Medical Services: For the Term of this Agreement set forth in Section 3.1, if a
federally funded clinic or emergency hospital (in Exhibit A) provides a complete and
accurate Referral Form to ADMINISTRATOR in accordance with Section 1.1.2, and
ADMINISTRATOR has received any necessary written preliminary assurances from
COUNTY's Director of Department of Public Health, or his/her designee (if required under
Section 1.1.4) COUNTY shall reimburse ADMINISTRATOR for the fees incurred by the
medical providers (in Exhibit B) for providing non-emergency specialty care services within
the scope of services (in Exhibit D) to the Beneficiaries according to the fee-for-service
Medi-Cal Rates incurred during the date of service and subject to the availability of A.B.
2731 reimbursement funding in Section 2.2 below.
Third Party Administration Fees: For the Term of this Agreement set forth in Section 3.1,
COUNTY shall reimburse ADMINISTRATOR for third party administration fees at the rate
of five percent (5%) for the total amount of fees incurred in processing claims from the
medical providers (in Exhibit B) with respect to the Beneficiaries for non-emergency
specialty care services (in Exhibit D), subject to available A.B. 2731 funding set forth in
Section 2.2, and the Referral Forms being complete and accurate in accordance with Sections
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1.1.2 and 1.1.4. ADMINISTRATOR shall not be entitled to any reimbursement for non-
emergency specialty medical services and third party administration fees once the A.B. 2731
Reimbursement Funding is exhausted.
2.1.1 Reimbursement Contingencies for Specialty Medical Services and Third
Party Administration FeesNalid Claims: ADMINISTRATOR shall only be
entitled to reimbursement for specialty medical services performed by the medical
providers listed in Exhibit B and third party administration fees under this Section
2.1, if ADMINISTRATOR: (1) selects Beneficiaries ±rom referrals only provided
by federally funded clinics and/or emergency hospitals listed in Exhibit A; (2) has
received from the federally funded clinics and/or emergency hospitals listed in
Exhibit A, a complete and accurate Referral Form as set forth in Sections 1.1.2
and 1.1.4; (3) receive written preliminary assurances from the COUNTY's
Director of Department of Public Health, or his/her designee, on Referral Forms
marked "yes" to "Medi-Cal application pending"; (4) medical providers in Exhibit
B, attached hereto, seek reimbursement for necessary non-emergency specialty
medical services as listed in Exhibit D, and not any excluded services listed in
Section 1.2.1; (5) ensures there is available A.B. 2731 Reimbursement Funding to
process payment in accordance with the maximum payment limit in Section 2.2;
(6) processes payment in accordance with Section 2.2; and (7) submits invoice/s
to COUNTY as set forth in Section 2.4.
2.2 Maximum Payment/Availability of A.B. 2731 Reimbursement Funding: In no event shall
the total available funds for A.B. 2731 reimbursement for non-emergency specialty medical
services provided by medical providers (listed in Exhibit B) and third party administrative
fees charged by ADMINISTRATOR be in excess of Five Million Five Hundred Sixty Nine
Thousand Three Hundred Ninety Two Dollars ($5,569,392.00) ("Available Funding").
ADMINISTRATOR shall not be entitled to receive any further payment from COUNTY
upon receipt of valid claims from medical providers and third party administrative fees that
reach the Available Funding limit. This Agreement shall automatically terminate once the
Available Funding has been exhausted, as set forth in Section 3 herein.
2.2.1 Notice of 85% Expenditure of Funds/Winding Down Procedure:
ADMINISTRATOR agrees that when the total combined amount of valid claims
received and third party administrative fees charged reach eighty-five percent
(85%) of the Available Funding (i.e., Four Million Seven Hundred Thirty Three
Thousand Nine Hundred Eighty Three Dollars and Twenty Cents
($4,733,983.20)), ADMINISTRATOR shall immediately provide written notice
to: (a) the federally funded clinics and emergency hospitals listed in Exhibit A;
(b) the medical providers listed in Exhibit B; and (c) COUNTY.
The written notice shall contain the following points:
There remains only fifteen percent (15%) in A.B. 2731 Reimbursement
Funding
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The medical providers are required to forward all claims for A.B. 2731
Reimbursement Funding to ADMINISTRATOR within the next thirty
(30) calendar days, and the medical providers shall only receive
reimbursement for a pro-rata portion of their claims on the remaining
available A.B. 2731 reimbursement funds if the remaining funds are
less than the total amount of the claims and third party administrative
fees combined.
Federally funded clinics and/or emergency hospitals listed in Exhibit A
shall have ten (1 0) calendar days to submit accurate and complete
Referral Forms to ADMINISTRATOR, and there will be no guarantee
that those Referral Forms will be processed and/or accepted by
ADMINISTRATOR
ADMINISTRATOR will provide written notice in the future to the
medical providers, federally funded clinics, and emergency hospitals if
additional A.B. 2731 Reimbursement Funding becomes available
In the event, the claims from medical providers in the thirty (30) calendar days
after eighty-five percent (85%) of the Available Funding is expended, does not
exhaust the Available Funding Limit in Section 2.2, ADMINISTRATOR shall
process payment for the full amount of those claims in accordance with this
Section 2. After such reimbursement, ADMINISTRATOR shall provide written
notice to the medical providers and federally funded clinics and emergency
hospitals (in Exhibits A and B), with a copy to COUNTY, indicating that there is
available funding. The notice shall state that the medical providers shall have an
additional thirty (30) calendar days to submit claims to ADMINISTRATOR and
that the federally funded clinics and emergency hospitals shall have an additional
ten (10) calendar days to submit accurate and complete Referral Forms to
ADMINISTRATOR. The ADMINISTRATOR shall add to the notice that there
will be no guarantee that the Referral Forms will be processed and/or accepted by
ADMINISTRATOR. The ADMINISTRATOR shall process payment on the
remaining Available Funding on a pro-rata basis for a portion of their claims if the
remaining Available Funding is less than the total amount of the claims and third
party administrative fees combined.
The foregoing winding down procedure shall continue and repeat until the
Available Funding is completely exhausted.
2.3 Waiver: ADMINISTRATOR, including its respective predecessors, successors,
subcontractors, agents, officers, representatives, executors, beneficiaries and assigns, agrees
and acknowledges that it will release and forever discharge the COUNTY from any and all
actions, causes of action, claims, suits, judgments, demands, liens, promises, agreements,
contract, obligations, rights, penalties, sanctions, damages, punitive damages, attorneys' fees,
costs, losses, liabilities, demands, fees or expenses of any kin or nature it may or will have
against the COUNTY with respect to reimbursement for any and all claims relating to
services Beneficiaries received under this Agreement and third party administration fees that
would exceed the A vail able Funding in Section 2.2.
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2.4 Billing/Invoicing: ADMINISTRATOR shall accept claims from the medical providers
(listed in Exhibit B) who provide non-emergency specialty medical services to Beneficiaries
within the scope of services (in Exhibit D) in accordance with the terms of this Agreement
and subject to the compensation contingencies set forth in Sections 2.1 and 2.2. After
accepting a claim that meets the compensation contingencies in Sections 2.1 and 2.2
ADMINISTRATOR shall submit an invoice to the COUNTY for reimbursement of such
claim.
Such invoice for reimbursement shall contain the following information: (1) the date(s) of
service; (2) full and complete descriptions of each service provided; (3) the cost of each
specialty medical service provided; (4) cost of the third party administrative fee; (5) the total
amount billed by ADMINISTRATOR to date for specialty medical services and third party
administration fees under this Agreement; (6) the Medi-Cal codes utilized to determine cost
of service; and (7) the name and current contact information of the Beneficiary who received
such services.
2.4.1 Claims shall be submitted to County electronically or on a HCFA-1500 billing
form.
2.4.2 ADMINISTRATOR agrees to submit invoices/reimbursement claims to
COUNTY for services referred under this Agreement no later than ninety (90)
days after the service was delivered.
2.4.3 COUNTY agrees to reimburse ADMINISTRATOR, subject to the contingencies
set forth in Sections 2.1, and 2.2 forty-five (45) calendar days after receipt and
verification of the invoices from ADMINISTRATOR.
2.4.4 Invoices shall be submitted to County of Fresno, Department of Public Health,
P.O. Box 11867, Fresno, CA 93775, Attention: DPH Director.
2.4.5 Invoices to COUNTY for specialty medical services shall be coded and billed
correctly pursuant to the fee-for-service Medi-Cal rate in effect at the time the
medical service was rendered and according to the procedure code located at:
http:; i ti ks.mcd i -c~d .ca.t_.:m ptthsdoco 1\<Jll.'si Ralcsll Ollll' .asp
SECTION III-TERM & TERMINATION
3.1 Term: This Agreement shall become effective on the 20th day of April, 2015 and shall
terminate one (1) year later on the 19th day of April, 2016, unless terminated
earlier under Section 3 .2, herein.
In the event the maximum compensation limit under Section 2.2 is not reached by
the 19th day of April, 2016, this Agreement shall be automatically extended for
two (2) additional twelve (12) month periods upon the same terms and conditions
herein set forth, unless written notice of nonrenewal or termination as set forth in
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Section 3.2 is provided by COUNTY or COUNTY's DPH Director or his/her
designee.
3.2 Termination:
3.2.1 Non-Allocation of Funds: The terms of this Agreement, and the services to be
provided thereunder, are contingent on the approval of funds by the appropriating
government agency. Should sufficient funds not be allocated, the services
provided may be modified, or this Agreement terminated at any time by giving
ADMINISTRATOR thirty (30) days advance written notice.
3.2.2 Maximum Payment: Upon COUNTY reimbursing ADMINISTRATOR up to the
maximum payment set forth under Section 2.2 for services provided pursuant to
this Agreement and third party administrative fees combined, this Agreement
shall automatically terminate immediately. In this instance, no written notice of
termination shall be required of the COUNTY.
3.2.3 Material Breach of Contract: Except for the foregoing in Sections 3.2.1 and 3.2.2
this Agreement may be terminated by either Party should the other Party
materially default in the performance of this Agreement. Either Party, upon
issuing at least a thirty (30) calendar day prior written notice to the other Party,
may terminate this Agreement upon the material breach of this Agreement by the
other Party.
The Parties are encouraged to resolve any dispute informally prior to the thirty
(30) calendar day termination notice to correct the basis for termination. If so
corrected to the reasonable satisfaction of the non-defaulting Party, this
Agreement shall continue according to the terms and conditions herein.
3.2.4 Without Cause: This Agreement may be terminated by either Party without cause
upon either Party issuing at least a thirty (30) calendar day written notice of
termination to the other Party.
Upon termination or expiration of this Agreement under Section 3 each Party
shall continue to remain liable for their own obligations or liabilities, as indicated
herein, originating prior to termination of this Agreement.
SECTION IV-MODIFICATION AND ASSIGNMENT
4.1 Modification: With the exception of deletions or additions of medical providers under
Section 4.3, herein, and federally funded clinics and/or emergency hospitals under Section
4.4, herein, any matters of this Agreement may be modified by the written consent of all
Parties without, in any way, affecting the remainder.
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4.2 Non-Assignment: This Agreement is personal in nature and the rights or duties hereunder
shall not be transferred, delegated, or assigned by either Party, without the prior written
consent of the other Party.
4.3 Adding/Deleting Medical Providers: COUNTY's Director of the Department of Public
Health shall have the sole discretion to add or delete the medical providers listed in Exhibit
B, attached hereto. COUNTY shall place ADMINISTRATOR on notice immediately upon
deleting or adding medical providers on Exhibit B.
4.4 Adding/Deleting Federally Funded Clinics and/or Emergency Hospitals: COUNTY's
Director of the Department of Public Health shall have the sole discretion to add or delete
the federally funded clinics and/or emergency hospitals that coordinate with federally
funded clinics listed in Exhibit A, attached hereto. COUNTY shall place
ADMINISTRATOR on notice immediately upon deleting or adding federally funded clinics
and/or emergency hospitals that coordinate with federally funded clinics listed in Exhibit A.
SECTION V-INDEPENDENT CONTRACTOR
5.1 Independent Contractor: In the performance of the work, duties, obligations assumed by
ADMINISTRATOR under this Agreement, it is mutually understood and agreed that
ADMINISTRATOR, including its subcontractors, 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 venture, partner, or associate
of COUNTY. Furthermore, COUNTY shall have no right to control or supervise or direct
the manner or method by which ADMINISTRATOR shall perform its work and function.
However, COUNTY shall retain the right to administer this Agreement so as to verify that
ADMINISTRATOR is performing its obligations in accordance with the terms and
conditions thereof. COUNTY and ADMINISTRATOR shall comply with all applicable
provisions of law and the rules and regulations, if any, of governmental authorities having
jurisdiction over matters which are directly or indirectly the subject of this Agreement.
Because of its status as an independent contractor, ADMINISTRATOR shall have
absolutely no right to employment rights and benefits available to COUNTY employees.
ADMINISTRATOR shall be solely liable and responsible for providing to, or on behalf of,
its employees all legally required employee benefits. In addition, ADMINISTRATOR shall
be solely responsible and save COUNTY harmless from all matters relating to the payment
of ADMINISTRATOR's employees, including compliance with Social Security
withholding and all other regulations governing such matters. It is acknowledged that
during the term of this Agreement, ADMINISTRATOR may be providing services to others
unrelated to the COUNTY or to this Agreement.
SECTION VI-NOTICES
6.1 Notices: Any notice required to be given pursuant to the terms and provisions of this
Agreement shall be in writing and may either be personally delivered or sent by registered
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or certified mail in the United States Postal Service, return receipt requested, postage
prepaid, addressed to each party at the address which follows:
ADMINISTRATOR:
Advantek Benefit Administrators
Attn: Chris Cheney
Title: CFO
Address: 1180 E. Shaw A venue
Fresno, CA 93 71 0
COUNTY:
Director, County of Fresno
Department of Public Health
P.O. Box 11867
Fresno, CA 93775
SECTION VII-HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY
ACT
7.1 The parties to this Agreement shall be in strict conformance with all applicable Federal and
State of California laws and regulations, including but not limited to Sections 5328, 10850,
and 14100.2 et seq. ofthe Welfare and Institutions Code, Sections 2.1 and 431.300 et seq. of
Title 42, Code of Federal Regulations (CFR), Section 56 et seq. of the California Civil
Code, and the Health Insurance Portability and Accountability Act (HIP AA), including but
not limited to Section 1320 D et seq. of Title 42, United States Code (USC) and its
implementing regulations, including, but not limited to Title 45, CFR, Sections 142, 160,
162, and 164, The Health Information Technology for Economic and Clinical Health Act
(HITECH) regarding the confidentiality and security of patient information, and the Genetic
Information Nondiscrimination Act (GINA) of2008 regarding the confidentiality of genetic
information.
Except as otherwise provided in this Agreement, ADMINISTRATOR, as a Business
Associate of COUNTY, may use or disclose Protected Health Information (PHI) to perform
functions, activities or services for or on behalf of COUNTY, as specified in this
Agreement, provided that such use or disclosure shall not violate the Health Insurance
Portability and Accountability Act (HIP AA), 42 USC 1320d et seq. The uses and
disclosures of PHI may not be more expansive than those applicable to COUNTY, as the
"Covered Entity" under the HIPAA Privacy Rule (45 CFR 164.500 et seq.), except as
authorized for management, administrative or legal responsibilities of the Business
Associate.
7.2 ADMINISTRATOR shall protect, from unauthorized access, use, or disclosure of names and
other identifying information, including genetic information, concerning persons receiving
services pursuant to this Agreement, except where permitted in order to carry out data
aggregation purposes for health care operations [45 CFR Sections 164.504 (e)(2)(i), 164.504
(3)(2)(ii)(A), and 164.504 (e)(4)(i)] This pertains to any and all persons receiving services
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pursuant to a COUNTY funded program. This requirement applies to electronic PHI.
ADMINISTRATOR shall not use such identifying information or genetic information for
any purpose other than carrying out ADMINISTRATOR's obligations under this
Agreement.
7.3 ADMINISTRATOR shall not disclose any such identifying information or genetic
information to any person or entity, except as otherwise specifically permitted by this
Agreement, authorized by Subpart E of 45 CFR Part 164 or other law, required by the
Secretary, or authorized by the client/patient in writing. In using or disclosing PHI that is
permitted by this Agreement or authorized by law, ADMINISTRATOR shall make
reasonable efforts to limit PHI to the minimum necessary to accomplish intended purpose of
use, disclosure or request.
7.4 For purposes of the above sections, identifying information shall include, but not be limited
to name, identifying number, symbol, or other identifying particular assigned to the
individual, such as finger or voice print, or photograph.
7.5 For purposes ofthe above sections, genetic information shall include genetic tests of family
members of an individual or individual, manifestation of disease or disorder of family
members of an individual, or any request for or receipt of, genetic services by individual or
family members. Family member means a dependent or any person who is first, second,
third, or fourth degree relative.
7.6 ADMINISTRATOR shall provide access, at the request of COUNTY, and in the time and
manner designated by COUNTY, to PHI in a designated record set (as defined in 45 CFR
Section 164.501), to an individual or to COUNTY in order to meet the requirements of 45
CFR Section 164.524 regarding access by individuals to their PHI. With respect to
individual requests, access shall be provided within thirty (30) days from request. Access
may be extended if ADMINISTRATOR cannot provide access and provides individual with
the reasons for the delay and the date when access may be granted. PHI shall be provided in
the form and format requested by the individual or COUNTY.
ADMINISTRATOR shall make any amendment(s) to PHI in a designated record set at the
request of COUNTY or individual, and in the time and manner designated by COUNTY in
accordance with 45 CFR Section 164.526.
ADMINISTRATOR shall provide to COUNTY or to an individual, in a time and manner
designated by COUNTY, information collected in accordance with 45 CFR Section
164.528, to permit COUNTY to respond to a request by the individual for an accounting of
disclosures ofPHI in accordance with 45 CFR Section 164.528.
7.7 ADMINISTRATOR shall report to COUNTY, in writing, any knowledge or reasonable
belief that there has been unauthorized access, viewing, use, disclosure, security incident, or
breach of unsecured PHI not permitted by this Agreement of which it becomes aware,
immediately and without reasonable delay and in no case later than two (2) business days of
discovery. Immediate notification shall be made to COUNTY's Information Security
13
Officer and Privacy Officer and COUNTY's DPH HIPAA Representative, within two (2)
business days of discovery. The notification shall include, to the extent possible, the
identification of each individual whose unsecured PHI has been, or is reasonably believed to
have been, accessed, acquired, used, disclosed, or breached. ADMINISTRATOR shall take
prompt corrective action to cure any deficiencies and any action pertaining to such
unauthorized disclosure required by applicable Federal and State Laws and regulations.
ADMINISTRATOR shall investigate such breach and is responsible for all notifications
required by law and regulation or deemed necessary by COUNTY and shall provide a
written report of the investigation and reporting required to COUNTY's Information
Security Officer and Privacy Officer and COUNTY's DPH HIPAA Representative. This
written investigation and description of any reporting necessary shall be postmarked within
the thirty (30) working days of the discovery ofthe breach to the addresses below:
County of Fresno
Dept. of Public Health
HIP AA Representative
(559) 600-6439
P.O. Box 11867
Fresno, CA 93775
County of Fresno
Dept. of Public Health
Privacy Officer
(559) 600-6405
P.O. Box 11867
Fresno, CA 93775
County of Fresno
Information Technology Services
Information Security Officer
(559) 600-5800
2048 N. Fine Street
Fresno, CA 93727
7.8 ADMINISTRATOR shall make its internal practices, books, and records relating to the use
and disclosure of PHI received from COUNTY, or created or received by the
ADMINISTRATOR on behalf of COUNTY, in compliance with HIPAA's Privacy Rule,
including, but not limited to the requirements set forth in Title 45, CPR, Sections 160 and
164. ADMINISTRATOR shall make its internal practices, books, and records relating to the
use and disclosure of PHI received from COUNTY, or created or received by the
ADMINISTRATOR on behalfofCOUNTY, available to the United States Department of
Health and Human Services (Secretary) upon demand.
ADMINISTRATOR shall cooperate with the compliance and investigation reviews
conducted by the Secretary. PHI access to the Secretary must be provided during the
ADMINISTRATOR's normal business hours, however, upon exigent circumstances access
at any time must be granted. Upon the Secretary's compliance or investigation review, if
PHI is unavailable to ADMINISTRATOR and in possession of a Subcontractor, it must
certify efforts to obtain the information to the Secretary.
7.9 Safeguards
ADMINISTRATOR shall implement administrative, physical, and technical safeguards as
required by the HIP AA Security Rule, Subpart C of 45 CPR 164, that reasonably and
appropriately protect the confidentiality, integrity, and availability of PHI, including
electronic PHI, that it creates, receives, maintains or transmits on behalf of COUNTY and to
prevent unauthorized access, viewing, use, disclosure, or breach of PHI other than as
provided for by this Agreement. ADMINISTRATOR shall conduct an accurate and
thorough assessment of the potential risks and vulnerabilities to the confidential, integrity
and availability of electronic PHI. ADMINISTRATOR shall develop and maintain a
14
written information privacy and security program that includes administrative, technical and
physical safeguards appropriate to the size and complexity of ADMINISTRATOR's
operations and the nature and scope of its activities. Upon COUNTY's request,
ADMINISTRATOR shall provide COUNTY with information concerning such safeguards.
ADMINISTRATOR shall implement strong access controls and other security safeguards
and precautions in order to restrict logical and physical access to confidential, personal (e.g.,
PHI) or sensitive data to authorized users only. Said safeguards and precautions shall
include the following administrative and technical password controls for all systems used to
process or store confidential, personal, or sensitive data:
7.9.1 Passwords must not be:
a. Shared or written down where they are accessible or recognizable by
anyone else; such as taped to computer screens, stored under
keyboards, or visible in a work area;
b. A dictionary word; or
c. Stored in clear text
7.9.2 Passwords must be:
a. Eight (8) characters or more in length;
b. Changed every ninety (90) days;
c. Changed immediately if revealed or compromised; and
d. Composed of characters from at least three (3) of the following four
(4) groups from the standard keyboard:
1. Upper case letters (A-Z);
2. Lowercase letters (a-z);
3. Arabic numerals (0 through 9); and
4. Non-alphanumeric characters (punctuation symbols).
ADMINISTRATOR shall implement the following security controls on each workstation or
portable computing device (e.g., laptop computer) containing confidential,
personal, or sensitive data:
7.9.2.1 Network-based firewall and/or personal firewall;
7.9.2.2 Continuously updated anti-virus software; and
7.9.2.3 Patch management process including installation of all operating
system/software vendor security patches.
ADMINISTRATOR shall utilize a commercial encryption solution that has received FIPS
140-2 validation to encrypt all confidential, personal, or sensitive data stored on portable
electronic media (including, but not limited to, compact disks and thumb drives) and on
portable computing devices (including, but not limited to, laptop and notebook computers).
ADMINISTRATOR shall not transmit confidential, personal, or sensitive data via e-mail or
15
other internet transport protocol unless the data is encrypted by a solution that has been
validated by the National Institute of Standards and Technology (NIST) as conforming to
the Advanced Encryption Standard (AES) Algorithm. ADMINISTRATOR must apply
appropriate sanctions against its employees who fail to comply with these safeguards.
ADMINISTRATOR must adopt procedures for terminating access to PHI when employment of
employee ends.
7.10 Mitigation of Harmful Effects
ADMINISTRATOR shall mitigate, to the extent practicable, any harmful effect that is
suspected or known to ADMINISTRATOR of an unauthorized access, viewing, use,
disclosure, or breach of PHI by ADMINISTRATOR or its Subcontractors in violation of the
requirements ofthese provisions. ADMINISTRATOR must document suspected or known
harmful effects and the outcome.
7.11 ADMINISTRATOR's Subcontractors
ADMINISTRATOR shall ensure that any of its contractors, including subcontractors, if
applicable, to whom ADMINISTRATOR provides PHI received from or created or received
by ADMINISTRATOR on behalf of COUNTY, agree to the same restrictions, safeguards,
and conditions that apply to ADMINISTRATOR with respect to such PHI and to
incorporate, when applicable, the relevant provisions of these provisions into each
subcontract or sub-award to such agents or Subcontractors.
7.12 Employee Training and Discipline
ADMINISTRATOR shall train and use reasonable measures to ensure compliance with the
requirements of these provisions by employees who assist in the performance of functions
or activities on behalf of COUNTY under this Agreement and use or disclose PHI and
discipline such employees who intentionally violate any provisions of these provisions,
including termination of employment.
7.13 Termination for Cause
Upon COUNTY's knowledge of a material breach of these provisions by
ADMINISTRATOR, COUNTY shall either:
7.13.1 Provide an opportunity for ADMINISTRATOR to cure the breach or end the
violation and terminate this Agreement if ADMINISTRATOR does not cure the breach or
end the violation within the time specified by COUNTY; or
7.13.2 Immediately terminate this Agreement if ADMINISTRATOR has breached a
material term of these provisions and cure is not possible.
7.13.3 If neither cure nor termination is feasible, the COUNTY's Privacy Officer shall
report the violation to the Secretary of the U.S. Department of Health and Human Services.
16
7.14 Judicial or Administrative Proceedings
COUNTY may terminate this Agreement in accordance with the terms and conditions of
this Agreement as written hereinabove, if: (1) ADMINISTRATOR is found guilty in a
criminal proceeding for a violation ofthe HIPAA Privacy or Security Laws or the HITECH
Act; or (2) there is a finding or stipulation that the ADMINISTRATOR has violated a
privacy or security standard or requirement of the HITECH Act, HIP AA or other security or
privacy laws in an administrative or civil proceeding in which the ADMINISTRATOR is a
party.
7.15 Effect of Termination
Upon termination or expiration of this Agreement for any reason, ADMINISTRATOR shall
return or destroy all PHI received from COUNTY (or created or received by
ADMINISTRATOR on behalfofCOUNTY) that ADMINISTRATOR still maintains in any
form, and shall retain no copies of such PHI. If return or destruction of PHI is not feasible,
it shall continue to extend the protections of these provisions to such information, and limit
further use of such PHI to those purposes that make the return or destruction of such PHI
infeasible. This provision shall apply to PHI that is in the possession of Subcontractors or
agents, if applicable, of ADMINISTRATOR. If ADMINISTRATOR destroys the PHI data,
a certification of date and time of destruction shall be provided to the COUNTY by
ADMINISTRATOR.
7.16 Disclaimer
COUNTY makes no warranty or representation that compliance by ADMINISTRATOR
with these provisions, the HITECH Act, HIP AA or the HIP AA regulations will be adequate
or satisfactory for ADMINISTRATOR's own purposes or that any information in
ADMINISTRATOR's possession or control, or transmitted or received by
ADMINISTRATOR, is or will be secure from unauthorized access, viewing, use,
disclosure, or breach. ADMINISTRATOR is solely responsible for all decisions made by
ADMINISTRATOR regarding the safeguarding of PHI.
7.17 Amendment
The parties acknowledge that Federal and State laws relating to electronic data security and
privacy are rapidly evolving and that amendment of these provisions may be required to
provide for procedures to ensure compliance with such developments. The parties
specifically agree to take such action as is necessary to amend this agreement in order to
implement the standards and requirements of HIP AA, the HIP AA regulations, the HITECH
Act and other applicable laws relating to the security or privacy of PHI. COUNTY may
terminate this Agreement upon thirty (30) days written notice in the event that
ADMINISTRATOR does not enter into an amendment providing assurances regarding the
safeguarding of PHI that COUNTY in its sole discretion, deems sufficient to satisfy the
standards and requirements of HIP AA, the HIP AA regulations and the HITECH Act.
17
7.18 No Third-Party Beneficiaries
Nothing express or implied in the terms and conditions of these provisions is intended to
confer, nor shall anything herein confer, upon any person other than COUNTY or
ADMINISTRATOR and their respective successors or assignees, any rights, remedies,
obligations or liabilities whatsoever.
7.19 Interpretation
The terms and conditions in these provisions shall be interpreted as broadly as necessary to
implement and comply with HIP AA, the HIP AA regulations and applicable State laws. The
parties agree that any ambiguity in the terms and conditions of these provisions shall be
resolved in favor of a meaning that complies and is consistent with HlP AA and the HIP AA
regulations.
7.20 Regulatory References
A reference in the terms and conditions of these provisions to a section in the HIP AA
regulations means the section as in effect or as amended.
7.21 Survival
The respective rights and obligations of ADMINISTRATOR as stated in this Section shall
survive the termination or expiration of this Agreement.
7.22 No Waiver of Obligations
No change, waiver or discharge of any liability or obligation hereunder on any one or more
occasions shall be deemed a waiver of performance of any continuing or other obligation, or
shall prohibit enforcement of any obligation on any other occasion.
SECTION VIII -MISCELLANEOUS PROVISIONS
8.1 Indemnification: ADMINISTRATOR 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
ADMINISTRATOR, and its Subcontractors, 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 ADMINISTRATOR, and its Subcontractors,
agents, or employees under this Agreement.
COUNTY agrees to protect, defend, indemnify and hold harmless, and at
ADMINISTRATOR's request, defend ADMINISTRATOR, its Subcontractors, officers,
agents, and employees, from any and all costs and expenses, damages, liabilities, claims and
18
losses occurring or resulting to ADMINISTRATOR in connection with the performance, or
failure to perform, by COUNTY, and 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 COUNTY, its officers, agents, or employees
under this Agreement.
8.2 Insurance: Without limiting a Party's right to obtain indemnification from the other Party
or any third parties, ADMINISTRATOR, at its sole expense, shall maintain in full force and
effect, the following insurance policies throughout the term of this Agreement:
8.2.1 Commercial General Liability: 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 coverage including completed operations, product
liability, contractual liability, Explosion, Collapse, and Underground
(XCU), fire legal liability or any other liability insurance deemed
necessary because of the nature of the Agreement.
8.2.2 Professional Liability: If ADMINISTRATOR employs licensed
professional staff(e.g., PhD, MD, PA, NP, RN, LCSW, LMFT, LPCC) in
providing services, Professional Liability Insurance with limits of not less
than Three Million Dollars ($3,000,000) per occurrence, Five Million
Dollars ($5,000,000) annual aggregate.
This coverage shall be issued on a per claim basis. ADMINISTRATOR
agrees that it shall maintain, at its sole expense, in full force and effect for
a period of five (5) years following the termination of this Agreement, one
or more policies of professional liability insurance with limits of coverage
as specified herein.
8.2.3 Workers' Compensation: A policy of Workers' Compensation Insurance
for ADMINISTRATOR's employees as required by the California Labor
Code.
ADMINISTRATOR 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 the COUNTY, its
officers, agents and employees shall be excess only and not contributing
with insurance provided under ADMINISTRATOR's policies herein.
This insurance shall not be cancelled or changed without a minimum of
thirty (30) days advance written notice given to COUNTY.
19
Within thirty (30) days from the date ADMINISTRATOR executes this
Agreement, ADMINISTRATOR shall provide certificates of insurance
and endorsements as stated above for all of the foregoing policies, as
required herein, to the County of Fresno, Department of Public Health,
P.O. Box 11867, Fresno, California 93775, Attention: Contracts Section-
6th Floor, 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 ADMINISTRATOR'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 ADMINISTRATOR fails to keep in effect at all times
insurance coverage as herein provided, 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 from companies
possessing a current A.M. Best, Inc. rating of A FSC VII or better.
8.3 Non-Discrimination: During the performance of this Agreement, ADMINISTRATOR shall
not unlawfully discriminate against any employee or applicant for employment, or recipient
of services, because of race, religious creed, color, national origin, ancestry, physical
disability, mental disability, medical condition, genetic information, marital status, sex,
gender, gender identity, gender expression, age, sexual orientation, or military and veteran
status, pursuant to all applicable State of California and Federal statutes and regulations.
8.4 Records: Upon ADMINISTRATOR's commencement of this Agreement,
ADMINISTRATOR agrees to document claims medical providers in Exhibit B render to
Beneficiaries in accordance with all applicable State and Federal laws, rules, and regulations
for services performed.
In addition, ADMINISTRATOR shall maintain complete and accurate financial records
with respect to the specialty medical services rendered in this Agreement. All such records
shall be prepared in accordance with generally accepted accounting procedures, shall be
clearly identified, and shall be kept readily accessible and available for inspection, as
20
described in Section 8.4, herein. All such records shall be retained by ADMINISTRATOR
and kept accessible as required by State of California and Federal law.
8.5 Audits: ADMINISTRATOR shall at any time during business hours, and as often as the
COUNTY may deem necessary, make available to the COUNTY for examination of all its
records and data with respect to the matters covered by this Agreement.
ADMINISTRATOR shall, upon request by the COUNTY, permit the COUNTY to audit
and inspect all of its records and data necessary to ensure ADMINISTRATOR's compliance
with the terms of this Agreement.
If this Agreement exceeds ten thousand dollars ($1 0,000.00), ADMINISTRATOR shall be
subject to the examination and audit of the Auditor General for a period of three (3) years
after final payment under contract. (Gov't Code, §8546.7).
8.6 Disclosure of Self-Dealing Transactions: This provision is only applicable if
ADMINISTRATOR is operating as a corporation (a for-profit or non-profit corporation), or
if during the term of this Agreement, ADMINISTRATOR changes its status to operate as a
corporation.
Members of ADMINISTRATOR's Board of Directors shall disclose any self-dealing
transactions that they are a party to while ADMINISTRATOR is providing goods or
performing services under this Agreement. A self-dealing transaction shall mean a
transaction to which ADMINISTRATOR 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 Self-Dealing
Transaction Disclosure Form, attached hereto as Exhibit E and incorporated herein by this
reference and submitting it to the ADMINISTRATOR prior to commencing with the self-
dealing transaction or immediately thereafter.
8. 7 Severability: In the event any provision of this Agreement is or becomes invalid or
unenforceable, the remainder of the provisions shall remain in full force and effect.
8.8 No Third Party Beneficiaries: This Agreement has been entered into solely for the benefit
of the Parties hereto. Nothing in this Agreement is intended to benefit or confer any rights
or remedies on any other person or parties.
8.9 Authority: Each Party represents and warrants to the other that it has full and complete
authority, corporate, legal, and otherwise, to enter into this Agreement and that the
individuals executing this Agreement on its behalf are duly authorized to do so.
8.10 Governing Law: The validity of this Agreement and any of its terms and provisions, as
well as the rights and duties of the parties hereunder, shall be interpreted and construed
pursuant to and in accordance with the laws of the State of California. Legal venue shall
reside in Fresno County.
21
8.11 Entire Agreement: This Agreement, including Exhibits A through F, herein, constitutes
the entire agreement between ADMINISTRATOR and COUNTY with respect to the subject
matter hereof and supersedes all previous Agreements, negotiations, proposals,
commitments, writings, advertisements, publications, and understanding of any nature
whatsoever unless expressly included in this Agreement.
22
IN WITNESS WHEREOF, the parties have affixed their signatures as of the date below
written:
SANTE HEALTH SYSTEM, INC. d.b.a COUNTY OF FRESNO
ADV ANTEK BENEFIT ADMINISTRATORS
By: __ ~ __ -· __ -rc ____ J~'---~-:_-~ By: ~-~
Vice~d of Supervisors
PrintName: ~ ~ WL\lS
Title:
Date:
-----------------------
Chief Executive Officer,
Authorized Representative
-----------------------
By:~-~
Print Name: Qh(~'j
Title:
Date:
-----------------------ChiefFinancial Officer,
Authorized Representative
----------------------
23
Date: __ tf~l~------"-1-t-l---=1 '5'------
BERNICE E. SEIDEL, Clerk
Board of Supervisors
By '~..¥~ C :1), \:J:y~
Date: 4 111 15 /
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
APPROVED AS TO LEGAL FORM:
DANIEL C. CEDERBORG, COUNTY COUNSEL
!.&~$( By: -(2 --------------------
APPROVED AS TO ACCOUNTING FORM:
VICKI CROW, C.P.A., AUDITOR-CONTROLLER/
TREASURER-TAX COLLECTOR
REVIEWED AND RECOMMENDED FOR APPROVAL:
By:
David Pomaville, Director
Department of Public Health
Fund/Subclass: 1 0000
Organization: 52,40
Account No: 7295
CK
24
EXHIBIT A
Referrals to ADMINISTRATOR shall derive from the following Federally Funded Clinics and
Emergency Hospitals:
Clinica Sierra Vista-Divisadero
145 N. Clark St.
Fresno, CA 93701
Phone (559) 457-5900/FAX (559) 457-5990
Clinica Sierra Vista-Easton
5784 S. Elm Ave.
Fresno, CA 93706
Phone (559) 457-5600/FAX (559) 457-5690
Clinica Sierra Vista-Elm
2760 S. Elm Ave.
Fresno, CA 93706
Phone (559) 457-5314/FAX (559) 457-5390
Clinica Sierra Vista-Elm
2740 S. Elm Ave.
Fresno, CA 93 706
Phone (559) 457-5200/FAX (559) 457-5290
Clinica Sierra Vista-Elm
2756 S. Elm Ave.
Fresno, CA 93706
Phone (559) 457-5345/FAX (559) 457-5395
Clinica Sierra Vista-Garland
3727 N. First St., #106
Fresno, CA 93726
Phone (559) 457-6900/FAX (559) 457-6990
Clinica Sierra Vista-North Fine
1945 N. Fine Ave., #100
Fresno, CA 93727
Phone (559) 457-5650/FAX (559) 457-5695
Clinica Sierra Vista-Orange & Butler
1350 S. Orange Ave.
Fresno, CA 93702
Phone (559) 457-5400/FAX (559) 457-5491
Clinica Sierra Vista-Regional Medical
2505 E. Divisadero St.
Fresno, CA 93721
Phone (559) 457-5500/FAX (559) 457-5599
25
United Health Centers-Huron
16928 lith St.
Huron, CA 93234
Phone (559) 945-2541/FAX (559) 945-1107
United Health Centers-Kerman
517 S. Madera Ave.
Kerman, CA 93630
Phone (559) 846-6330/FAX (559) 846-5553
United Health Centers-Mendota
121 Barboza St.
Mendota, CA 93640
Phone (559) 655-5000/FAX (559) 655-5000
United Health Centers-Orange Cove
445 11th St.
Orange Cove, CA 93646
Phone (559) 626-4031/FAX (559) 626-4963
United Health Centers-Parlier
650 S. Zediker Ave.
Parlier, CA 93648
Phone (559) 646-3561/FAX (559) 646-6780
United Health Centers -Sanger
2502 Jensen Ave.
Sanger, CA 93657
Phone (559) 875-6000/FAX (559) 875-6016
United Health Centers -Reedley
1560 E. Manning Ave.
Reedley, CA 93654
Phone (559) 638-2019/FAX (559) 638-2136
United Health Centers -Raisin City
6425 W. Bowles Ave.
Raisin City, CA 93652
Phone (559) 233-0111/FAX (559) 233-0112
United Health Centers -Lemoore
1270 N. Lemoore Ave.
Lemoore, CA 93645
Phone (559) 924-2015/FAX (559) 925-0568
Clinica Sierra Vista-West Shaw
4739 W. Shaw Ave., #108
Fresno, CA 93722
Phone (559) 457-6800/FAX (559) 457-6890
Clinica Sierra Vista-West Fresno
302 Fresno St., Suite# 101
Fresno, CA 93706
Phone (559) 457-5700/FAX (559) 457-5790
Clinica Sierra Vista-Gaston Middle School
1120 E. Church Ave.
Fresno, CA 93 706
Phone (559) 457-6970/FAX (559) 457-6695
Valley Health Team-San Joaquin
San Joaquin, CA 93660
Phone (559) 693-2462/Phone (559) 693-2467
FAX (559) 693-2398
Valley Health Team-Clovis
180 W. Shaw Ave., Suite B
Clovis, CA 93612
Phone (559) 203-6600/FAX (559) 326-5273
Adventist Health -Lemoore East
810 East D St.
Lemoore, CA 93245
Phone (559) 924-7711/FAX (559) 924-1658
Adventist Health -Coalinga
155 S. Fifth St.
Coalinga, CA 93210
Phone (559) 935-4282/FAX (559) 935-4285
Adventist Health-Parlier/Newmark
155 S. Newmark Ave.
Parlier, CA 93648
Phone (559) 646-1200/FAX (559) 646-6622
Adventist Health -Caruthers East
2357 W. Tahoe
Caruthers, CA 93609
Phone (559) 864-5200/FAX (559) 864-8403
Adventist Health -Reedley Cyprus
3 72 W. Cyprus
Reedley, CA 93654
Phone (559) 626-0882/F AX (559) 643-8057
26
Valley Health Team-Kerman
449 S. Madera Ave.
Kerman, CA 93630
Phone (559) 365-2970/FAX (559) 846-9353
Valley Health Team-Kerman
942 S. Madera Ave.
Kerman, CA 93630
Phone (559) 364-2980/FAX (559) 846-9157
Valley Health Team-Kerman Unified School
District
702 S. Eighth St.
Kerman, CA 93630
Phone (559) 364-2975/FAX (559) 846-5001
Valley Health Team-Sablan
927 0 St.
Firebaugh, CA 93600
Phone (559) 659-3037/FAX (559) 659-3434
Adventist Health -Kerman Central
275 S. Madera#20 1
Kerman, CA 93630
Phone (559) 846-5240/FAX (559) 846-3787
Adventist Health-Fowler
119 Sixth St.
Fowler, CA 93625
Phone (559) 834-1614/FAX (559) 834-0015
Adventist Health -Orange Cove
1455 Park Ave.
Orange Cove, CA 93646
Phone (559) 626-0882/FAX (559) 626-7498
Adventist Health -Sanger
1939 S. Academy
Sanger, CA 93657
Phone (559) 887-6900/FAX (559) 875-6011
Adventist Health -Caruthers
2440 W. Tahoe
Caruthers, CA 93609
Phone (559) 864-3212/FAX (559) 864-8510
Adventist Health -Kingsburg
1251 Draper St.
Kingsburg, CA 93631
Phone (559) 897-6610/FAX (559) 897-6611
Adventist Health -Huron
169I6 Fifth St.
Huron, CA 93234
Phone (559) 945-9090/FAX (559) 945-9100
Adventist Health-Riverdale
3567 Mt. Whitney Ave.
Riverdale, CA 93656
Phone (559) 867-7200/FAX (559) 867-0I52
Adventist Health -Kerman
1000 S. Madera
Kerman, CA 93630
Phone (559) 846-9370/FAX (559) 846-9352
Community Medical Centers -Emergency
Department
2823 Fresno St.
Phone (559) 459-3998/FAX (559) 459-7417
Community Medical Centers -Internal Medicine
290 N. Wayte, 2nd Floor
Fresno, CA 93 70 I
Phone (559) 459-5721/FAX (559) 459-5097
Community Medical Centers
290 N. Wayte, 1nd Floor
Fresno, CA 93701
Phone (559) 459-4300/FAX (559) 459-4555
27
Adventist Health-Reedley
1311 ll 1h St.
Reedley, CA 93654
Phone (559) 638-3227/FAX (559) 638-3799
Adventist Health-Selma Central
2I41 High St., #E
Selma, CA 93662
Phone (559) 89I-261I/FAX (559) 891-2616
Adventist Health-Selma Campus
I04I Rose Ave.
Selma, CA 93662
Phone (559) 856-6090/FAX (559) 856-6092
Community Medical Centers -Specialty Health
Center
290 N. Wayte, 2nd Floor
Fresno, CA 93 70 I
Phone (559) 459-7300/FAX (559) 459-5040
Community Medical Centers-Family Health
Center
290 N. Wayte, 2nd Floor
Fresno, CA 9370I
Phone (559) 459-5700/ FAX (559) 459-6109
EXHIBIT B
ADMINISTRATOR shall process claims under this Agreement from the following medical
providers:
Central California Ear Nose & Throat
1351 E. Spruce Ave.
Fresno, CA 93 720
Phone (559) 432-3303/FAX (559) 432-1468
Community Medical Centers
2823 Fresno Street
Fresno, CA 93 721
Phone (559) 459-6000
Central California Faculty Medical Group
2625 E. Divisadero
Fresno, CA 93721
Phone (559) 453-5200/FAX (559) 453-5233
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California Eye Institute
1360 E. Herndon
Fresno, CA 93 720
Phone (559) 449-5000/FAX (559) 449-5044
Community Medical Centers -Specialty Health
Center
290 N. Wayte, 2nd Floor
Fresno, CA 93 70 I
Phone (559) 459-7300/FAX (559) 459-5040
Central California Faculty Medical Group
Diana Johnson, Accounts Receivable Manager
2625 E. Divisadero
Fresno, CA 93 721
Phone (559) 453-5200 Ext. 292
Email: diana.johnson@ccfmg.org
EXHIBIT C
See attached Specialty Care Referral Form for A.B. 2731 (2014) Reimbursement Funding.
29
3.
4.
SPECIALTY CARE REFERRAL FORM FOR A.B. 2731 (2014)
REIMBURSEMENT FUNDING
Please submit this form to: Advantak Benefit Administrators
P.O. Box 1507, Fresno, CA 93716-1507
Attn: Dawn Dahl I FAX# 228-4279
Address: Street City State
Does patient have Restricted Medi-Cal? Yes No MEDS Aid Code: ________ _
5. ~ If"Yes", what is the patient's BIC/CIN Number? __________ _
6.
7.
8.
9.
~ If"No", is the patient's Medi-Cal application pending? Yes No Medi-Cal application date: ____ _
Contact Person in Requesting
Provider's Office:
Requesting Clinic/Hospital Address: Street
D Cardiology D Dermatology
D Inpatient D Laboratory Services Hospitalization
D Oncology D Ophthalmology
D Otolaryngology D Outpatient Surgery (ENT)
D
D
D
D
Name of PCP (if different than requesting
physician):
State Zip Code
Endocrinology D Gastroenterology
Neurology D Gynecology
Oral/Maxillofacial D Orthopedics
Pharmacy Services 0 Pulmonology
D Urology D Radiology, including Computerized Tomography (CT) Scans and Magnetic Resonance Imaging (MRI)
Page 1 of6
11. Referring Physician Comments:
12.
Client clinical data attached: Lab Reports: 0 X-ray: 0 Narrative Reports: 0 Medication Report: 0
0 Other:
I prefer to speak in the language checked below:
Prefiero hablar el idioma indicado a continuaci6n:
English!Ingles 0
Spanish!Espaiiol 0
Other/Otro 0 What language do you speak/Que idioma habla: ______ _
Please tell us which language or format you would prefer for your written information:
Por favor, indique cual idioma o formato usted prefiere para su informacion escrita:
English!Ingles 0
Spanish!Espaiiol 0
Other/Otro 0 What language do you read and write/En que idioma usted lee y
escribe: --------------
13 I , attest the following is true and correct under penalty and . '-------------------------
perJury
under the laws ofthe State of California: (1) I am currently a resident ofthe County of Fresno; (2) I do
not have a household income that exceeds 138% of the current Federal Poverty Level; (3) I have applied
for full scope Medi-Cal benefits; and (4) I have exhausted all other health care options available to me,
including but not limited to third party payors such as private insurance, the U.S. Department of Veterans
Affairs, Worker's Compensation, Medicare, through my own or my spouse's place of employment,
through my parent(s) or guardian(s), or motor vehicle or homeowner insurance coverage.
I acknowledge and understand that submission of this referral form is only to obtain necessary non-
emergency specialty care services listed herein and is solely dependent upon available funding pursuant
to Assembly Bill No. 2731 (2014) to reimburse qualified specialty care medical providers who may
perform such services.
I understand and acknowledge that I do not have a legal right to receive non-emergency specialty
care services under the A.B. 2731 (2014) reimbursement funding herein, and that such services
are dependent upon my continued eligibility and the availability of such funding.
(Applicant's Attestation continues on Page 3)
Page 2 of6
Further, I do waive, release and forever discharge any and all claims or actions, known or
unknown, that I may have against the County of Fresno and Sante Health System, d.b.a. Advantek
Benefit Administrators, pertaining to the processing of this referral form and receipt of non-
emergency specialty medical services from A.B. 2731 (2014) reimbursement funding.
Applicant Signature: ___________________ Date: _______ _
Yo, , doy fe que lo siguiente es verdadero y correcto bajo pena
de cometer perjurio conforme a las leyes del Estado de California: (1) que actualmente soy residente
en el Condado de Fresno; {2) no tengo ingresos familiares mayores a 138% del Nivel Federal de
Pobreza en vigor; (3) solicite los beneficios completos de Medi-Cal pero fueron negados; y (4) he
agotado todas las demas opciones de atenci6n de salud que estan disponibles para mi, incluyendo,
pero no limitadas a, terceros pagadores tales como seguros privados, el Departamento de Asuntos
para Veteranos, Compensaci6n para los Trabajadores, Medicare, por medio de mi propio Iugar de
empleo o el de mi c6nyuge, por medio de Ia cobertura de seguro de mi(s) padre(s) o tutor(es), o del
seguro de mi vehiculo o de propietario de mi hogar.
Yo reconozco y entiendo que la presentaci6n de este formulario de canalizaci6n fulicamente es para
obtener los servicios de atenci6n especializada de no emergencia anotados en este documento y que
depende linicamente del financiamiento disponible, de conformidad con Proyecto No. 2731 (2014) de la
Asamblea para reembolsar a los proveedores calificados de atenci6n medica especializada que puedan
realizar estos servicios.
Yo entiendo y reconozco que no ten go el derecho legal de recibir servicios de atencion
especializada de no emergencia de conformidad con el A.B. 2731 (2014) financiamiento de
reembolso aqui indicado, y que dichos servicios dependen de mi elegibilidad continuada y Ia
disponibilidad de dicho financiamiento.
Adicionalmente, renuncio a, libero y exonero para siempre de cualquiera y todas las
reclamaciones y acciones, conocidas o desconocidas, que yo pudiese tener en contra del Condado
de Fresno y Sante Health System, d.b.a. Advantek Benefit Administrators, con respecto al
procesamiento de este formulario de canalizacion y Ia recepcion de servicios medicos
especializados de no emergencia del financiamiento de reembolso A.B. 2731 (2014).
Firma del solicitante: Pecha: ----------------------------------------
Page 3 of6
14.
REQUESTING PRIMARY CARE PHYSICIAN'S ATTESTATION
I, , attest it is true and correct under penalty and perjury under
the laws of the State of California that I provided primary care services to the Applicant and that
Applicant has a need for non-emergency specialty medical services necessary to avoid endangerment to
life or health.
Physician Signature:-------------------Date: -------
OR
REQUESTING EMERGENCY DEPARTMENT PHYSICIAN'S ATTESTATION
I, , attest it is true and correct under penalty and perjury under
the laws of the State of California that I provided emergency department services to the Applicant and
that Applicant has a need for non-emergency specialty medical services necessary to avoid
endangerment to life or health.
Physician Signature: __________________ _ Date: -------
Page 4 of6
INSTRUCTIONS FOR COMPLETING
THE SPECIALTY CARE REFERRAL FORM
FOR A.B. 2731 (2014) REIMBURSEMENT FUNDING
1. Date of Request: Enter the date the form is completed.
2. Date Client Last Seen by Requesting Physician: Enter the date the patient was last seen by the referring
physician.
Patient Information
3. Patient Name: Enter the patient's last, first, and middle names, date of birth, age at the time of request
and gender.
4. Address and Phone Number: Enter the patient's street address, city, state, and zip code. Do not enter a
P.O. Box number unless that is the patient's street address. If the patient does not have an address
because he/she is homeless, enter "none" or "homeless" in this area. If left blank, the form is considered
incomplete and will be denied. Enter the patient's home or cell phone number, including the area code.
5. Does Patient have Restricted Medi-Cal: Circle "Yes" if the patient has Restricted Medi-Cal and enter
the MEDS Aid Code and patient's Medi-Cal BIC/CIN number. Circle "No" if the patient does not have
Restricted Medi-Cal. lf"No" is circled, answer whether or not the patient's Medi-Cal application is
pending by circling either "Yes" or "No" and enter the date the patient applied for Medi-Cal and leave
the MEDS Aid Code blank.
Requesting Clinic/Hospital Information
6. Requesting Physician, Tax ID #and Clinic Name: Enter the full name of the requesting physician,
which may be either the emergency care or primary care physician. Enter the Tax Identification number
of the federally funded clinic or emergency hospital. Enter the name of the clinic or hospital.
7. Contact Person in Requesting Provider's Office, Telephone#, Fax#, and Name of PCP: Enter the name
of the contact person in the clinic or hospital that can be contacted regarding the referral, his/her
telephone and FAX number, and the name ofthe patient's primary care physician ifthe requesting
physician is not the patient's primary care physician.
8. Requesting Clinic/Hospital Address: Enter the complete street address of the requesting clinic or
hospital. Do not enter the clinic or hospital's corporate address unless this is also the address where the
requesting physician provided medical care to the patient.
Referral Requested
9. Referral Requested: Check the box next to the type of referral requested and enter the CPT Code of the
requested specialty service where indicated.
Page 5 of6
Clinical Information
10. Medical Diagnosis, ICD-9 Code, and Date of Onset: The Medical Diagnosis, ICD-9 and Date of Onset
must be filled in by the referring physician.
11. Referring Physician Comments and Client Clinical Data Attached: Referring physician comments and
attaching any clinical data is optional for submittal ofthe Form to Advantek; however, if request is
approved, the specialist may require specific patient clinical data at his/her discretion.
Applicant's Language Preference
12. Spoken Language and Written Language: Patient must mark his/her language that he/she speaks and
reads and writes by checking the appropriate box. If "Other" is marked, enter the other language where
indicated. If client does not speak (including sign language), read or write, enter "None" where
appropriate.
Applicant's Attestation
13. Applicant's Attestation: The patient must fill in his/her full name, sign, and date the Applicant's
Attestation in his/her appropriate language. If the applicant indicates he/she speaks, reads, and/or writes
in a different language, the County may provide the applicant with an attestation translated to his/her
language for signature as soon as possible.
Physician's Attestation
14. Requesting Primary Care Physician's Attestation or Requesting Emergency Department Physician's
Attestation: Fill in the requesting physician's name and sign and date the appropriate attestation for
either primary care or emergency department.
Page 6 of6
EXHIBIT D
The scope of services for A.B. 2731 Reimbursement Funding consist of the following:
A. Endocrinology
B. Neurology
C. Pulmonology
D. Cardiology
E. Orthopedics
F. Gynecology
G. Otolaryngology (ENT)
H. Dermatology
I. Oncology
J. Gastroenterology
K. Oral and Maxillofacial Surgery
L. Ophthalmology
M. Inpatient Hospitalization
N. Outpatient Surgery
0. Radiology, including Computerized Tomography (CT) Scans and Magnetic
Resonance Imaging (MRI)
P. Laboratory Services
Q. Pharmacy Services
R. Urology
30
Exhibit E
SELF-DEALING TRANSACilON DISCWSURE 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).
31
(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 Sb?:nature
Signature: I Date: I
32