Loading...
HomeMy WebLinkAboutAgreement A-15-130-1 with Santé Health System.pdf1 FIRST AMENDED AND RESTATED AGREEMENT BETWEEN THE COUNTY OF FRESNO AND SANTE HEALTH SYSTEM This First Amended and Restated Agreement (“Restated Agreement”) is made and entered into this 26th day of September, 2017, by and between the COUNTY OF FRESNO, a Political Subdivision of the State of California (“COUNTY”) and SANTÉ HEALTH SYSTEM, d.b.a. ADVANTEK BENEFIT ADMINISTRATORS (“ADMINISTRATOR”), a California corporation. COUNTY and ADMINISTRATOR are referred to herein, collectively, as “Parties”, or “Party” individually. W I T N E S S E T H: Whereas, the Parties entered into that certain Agreement effective 20th day of April 2015, identified as COUNTY Agreement No. A-15-130, hereafter referred to as “Agreement”, whereby ADMINISTRATOR agreed to administer the Assembly Bill (“A.B.”) 2731 reimbursement fund; and Whereas, A.B. 2731 reimbursement fund will be replaced with and will be referred to as Non-Resident Specialty Care (NRSC) funding that the ADMINISTRATOR will utilize to administer for the provision of specialty medical services for indigent residents (“Beneficiaries” or Beneficiary”) that do not qualify for other health care options (e.g., full scope Medi -Cal, MISP); and Whereas, ADMINISTRATOR desires to administer the NRSC funds by selecting Beneficiaries from referrals it obtains from certain federally funded clinics and/or emergency medical hospitals that coordinate with federally funded clinics (see Referral List attached hereto as Exhibit A and incorporated by this reference herein) who meet certain eligibility criteria and allocate the NRSC funding on a first come first serve basis 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. Whereas, the Parties now desire to amend the Agreement and restate the Agreement in its entirety. Now, therefore, COUNTY and ADMINISTRATOR, in consideration of the covenants, agreements, and promises hereinafter set forth, agree as follows: SECTION I – RESPONSIBILITIES OF ADMINISTRATOR In consideration for the compensation set forth in Section 2, herein, ADMINISTRATOR shall be responsible to: 1.1 Select Beneficiaries From Referrals: ADMINISTRATOR shall be responsible to select Beneficiaries 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 with the below provisions. 2 1.1.1 Referral Form: ADMINISTRATOR shall administer NRSC funds by accepting the Specialty Care Referral Form (“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 NRSC funding. 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 of the 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 3 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 service, as provided in Exhibit D, attached hereto and incorporated by reference herein, the ADMINISTRATOR shall seek approval or denial of service from the COUNTY’s Department of Public Health Director or his/her designee as soon as possible so that the County may determine whether or not an approved provider is able and willing to provide the specialty care service requested on the Referral Form. The COUNTY’s Department of Public Health Director or his/her designee 4 shall respond in writing to the ADMINISTRATOR approving or denying the requested specialty care service. 10. Medical Diagnosis, ICD-10 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 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 ADMNISTRATOR for such referral claim/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 5 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 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 or other COUNTY Pre-Approved Specialty Care: ADMINISTRATOR shall only process referral claims that request reimbursement from the NRSC scope of services, which are listed in Exhibit D or which have been pre-approved by the COUNTY as in 1.1.2.1(9) of this Restated Agreement. COUNTY shall not be responsible for providing payment for those referral claims that are not within the scope of services listed in Exhibit D or otherwise have not been pre-approved by COUNTY, and reserves the right to deny payment on such claim/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 6 - 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, 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 Restated 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 7 medical providers (in Exhibit B) for providing non-emergency specialty care services within the scope of services (in Exhibit D) or which has been pre-approved by the COUNTY to the Beneficiaries according to the fee-for-service Medi-Cal Rates incurred during the date of service and subject to the availability of NRSC funding in Section 2.2 below. Third Party Administration Fees: For the Term of this Restated Agreement set forth in Section 3.1, COUNTY shall reimburse ADMINISTRATOR for third party administration fees at the monthly rate of either eight percent (8%) or Three Thousand Five Hundred and No/100 Dollars ($3,500.00) whichever is the greater amount 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 funding set forth in Section 2.2, and the Referral Forms being complete and accurate in accordance with Sections 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 funding is exhausted. 2.1.1 Reimbursement Contingencies for Specialty Medical Services and Third Party Administration Fees/Valid 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 from 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 or which have been pre-approved by the COUNTY, and not any excluded services listed in Section 1.2.1; (5) ensures there is available 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 Funds: In no event shall the total available funds for NRSC 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 Restated 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 8 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 available funding - The medical providers are required to forward all claims for reimbursement 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 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 (10) 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 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. 9 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 kind 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 Restated Agreement and third party administration fees that would exceed the Available Funding in Section 2.2. 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) or which were pre-approved by COUNTY, in accordance with the terms of this Restated 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 Restated 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 Restated 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://files.medi-cal.ca.gov/pubsdoco/Rates/RatesHome.asp 10 SECTION III - TERM & TERMINATION 3.1 Term: This Restated Agreement shall become effective upon execution and shall terminate on the 19th day of April, 2018, 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, 2018, this Restated Agreement may be extended for two (2) additional twelve (12) month periods upon written approval of both Parties no later than thirty (30) days prior to the first day of the next twelve (12) month extension period. The COUNTY’s Director of Public Health or designee is authorized to execute such written approval on behalf of COUNTY based on CONTRACTOR’S satisfactory performance. The same terms and conditions herein set forth, unless written notice of nonrenewal or termination as set forth in 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 Restated 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 Restated 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 Restated Agreement and third party administrative fees combined, this Restated 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 Restated Agreement may be terminated by either Party should the other Party materially default in the performance of this Restated Agreement. Either Party, upon issuing at least a thirty (30) calendar day prior written notice to the other Party, may terminate this Restated Agreement upon the material breach of this Restated 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 11 corrected to the reasonable satisfaction of the non-defaulting Party, this Restated Agreement shall continue according to the terms and conditions herein. 3.2.4 Without Cause: This Restated 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 Restated 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 Restated 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 Restated Agreement may be modified by the written consent of all Parties without, in any way, affecting the remainder. 4.2 Non-Assignment: This Restated 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 Restated 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 Restated Agreement so as to verify that ADMINISTRATOR is performing its obligations in accordance with the terms and conditions thereof. COUNTY and ADMINISTRATOR shall 12 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 Restated 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 Restated Agreement, ADMINISTRATOR may be providing services to others unrelated to the COUNTY or to this Restated Agreement. SECTION VI - NOTICES 6.1 Notices: Any notice required to be given pursuant to the terms and provisions of this Restated Agreement shall be in writing and may either be personally delivered or sent by registered 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: 7370 N. Palm Ave., Suite#101 Fresno, CA 93711 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 Restated 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. of the 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 (HIPAA), 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 13 information, and the Genetic Information Nondiscrimination Act (GINA) of 2008 regarding the confidentiality of genetic information. Except as otherwise provided in this Restated 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 Restated Agreement, provided that such use or disclosure shall not violate the Health Insurance Portability and Accountability Act (HIPAA), 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 Restated 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 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 Restated 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 Restated 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 Restated 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 of the 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 14 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 of PHI 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 Restated 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 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 of the breach to the addresses below: County of Fresno County of Fresno County of Fresno Dept. of Public Health Dept. of Public Health Information Technology Services HIPAA Representative Privacy Officer Information Security Officer (559) 600-6439 (559) 600-6405 (559) 600-5800 P.O. Box 11867 P.O. Box 11867 333 W. Pontiac Way Fresno, CA 93775 Fresno, CA 93775 Clovis, CA 93612 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, CFR, 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 behalf of COUNTY, available to the United States Department of Health and Human Services (Secretary) upon demand. 15 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 HIPAA Security Rule, Subpart C of 45 CFR 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 Restated 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 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 16 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 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 of these 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 17 or activities on behalf of COUNTY under this Restated 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 Restated 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 Restated 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. 7.14 Judicial or Administrative Proceedings COUNTY may terminate this Restated Agreement in accordance with the terms and conditions of this Restated Agreement as written hereinabove, if: (1) ADMINISTRATOR is found guilty in a criminal proceeding for a violation of the 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, HIPAA 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 Restated Agreement for any reason, ADMINISTRATOR shall return or destroy all PHI received from COUNTY (or created or received by ADMINISTRATOR on behalf of COUNTY) 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, HIPAA or the HIPAA regulations will be adequate 18 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 Restated Agreement in order to implement the standards and requirements of HIPAA, the HIPAA regulations, the HITECH Act and other applicable laws relating to the security or privacy of PHI. COUNTY may terminate this Restated 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 HIPAA, the HIPAA regulations and the HITECH Act. 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 HIPAA, the HIPAA 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 HlPAA and the HIPAA regulations. 7.20 Regulatory References A reference in the terms and conditions of these provisions to a section in the HIPAA 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 Restated Agreement. 7.22 No Waiver of Obligations 19 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 Restated 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 Restated 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 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 Restated 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 Restated 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 Restated 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 Restated 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. 20 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 Restated 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 Restated 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. Within thirty (30) days from the date ADMINISTRATOR executes this Restated 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 Restated 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 Restated Agreement upon the occurrence of such event. 21 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 Restated 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, s exual 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 Restated 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 Restated 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 in spection, as 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 Restated 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 Restated Agreement. If this Restated Agreement exceeds ten thousand dollars ($10,000.00), 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 Restated 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 Restated 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 22 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 Restated 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 Restated Agreement has been entered into solely for the benefit of the Parties hereto. Nothing in this Restated 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 Restated Agreement and that the individuals executing this Restated Agreement on its behalf are duly authorized to do so. 8.10 Governing Law: The validity of this Restated 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. 8.11 Entire Restated Agreement: This First Amended and Restated Agreement, including Exhibits A through E, 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 Restated Agreement and shall become effective upon execution. 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 ADVANTEK BENEFIT ADMINISTRATORS By:_<?e~_-_-:_~-"'-~- Print Name: J ~ n? ~ • ,J,.J !.J Title: -=~----~--~--------ChiefExecutive Officer, Authorized Representative Date: ct/r L/t "t By: ___ c!o.£~JC=-:.~(j!....:..:~~:!!f---- Print Name:_~{k.:,...<...e:.=-· ~~..:.=.!.h'"------ Title: tf' ~~-------------ChiefFinancial Officer, Authorized Representative Date:~ __ l(;_,t_lt+/_1 _,_1--____ _ 23 By:_JL=-· ~l_...:........=.:-:----:--- Chairman, Board of Supervisors BERNICE E. SEIDEL, Clerk Board of Supervisors By: d\.~ c.tP·) ~ Date: ~"""-~ ~to ,~c{ PLEASE SEE ADDITIONAL SIGNATURE PAGE ATTACHED 25 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 United Health Centers – Huron 16928 11th St. Huron, CA 93234 Phone (559) 945-2541/FAX (559) 945-1107 Clinica Sierra Vista – Easton 5784 S. Elm Ave. Fresno, CA 93706 Phone (559) 457-5600/FAX (559) 457-5690 United Health Centers – Kerman 517 S. Madera Ave. Kerman, CA 93630 Phone (559) 846-6330/FAX (559) 846-5553 Clinica Sierra Vista – Elm 2760 S. Elm Ave. Fresno, CA 93706 Phone (559) 457-5314/FAX (559) 457-5390 United Health Centers – Mendota 121 Barboza St. Mendota, CA 93640 Phone (559) 655-5000/FAX (559) 655-5000 Clinica Sierra Vista – Elm 2740 S. Elm Ave. Fresno, CA 93706 Phone (559) 457-5200/FAX (559) 457-5290 United Health Centers – Orange Cove 445 11th St. Orange Cove, CA 93646 Phone (559) 626-4031/FAX (559) 626-4963 Clinica Sierra Vista – Elm 2756 S. Elm Ave. Fresno, CA 93706 Phone (559) 457-5345/FAX (559) 457-5395 United Health Centers – Parlier 650 S. Zediker Ave. Parlier, CA 93648 Phone (559) 646-3561/FAX (559) 646-6780 Clinica Sierra Vista – Garland 3727 N. First St., #106 Fresno, CA 93726 Phone (559) 457-6900/FAX (559) 457-6990 United Health Centers – Sanger 2502 Jensen Ave. Sanger, CA 93657 Phone (559) 875-6000/FAX (559) 875-6016 Clinica Sierra Vista – North Fine 1945 N. Fine Ave., #100 Fresno, CA 93727 Phone (559) 457-5650/FAX (559) 457-5695 United Health Centers – Reedley 1560 E. Manning Ave. Reedley, CA 93654 Phone (559) 638-2019/FAX (559) 638-2136 Clinica Sierra Vista – Orange & Butler 1350 S. Orange Ave. Fresno, CA 93702 Phone (559) 457-5400/FAX (559) 457-5491 United Health Centers – Raisin City 6425 W. Bowles Ave. Raisin City, CA 93652 Phone (559) 233-0111/FAX (559) 233-0112 Clinica Sierra Vista – Regional Medical 2505 E. Divisadero St. Fresno, CA 93721 United Health Centers – Lemoore 1270 N. Lemoore Ave. Lemoore, CA 93645 26 Phone (559) 457-5500/FAX (559) 457-5599 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 Valley Health Team – Kerman 449 S. Madera Ave. Kerman, CA 93630 Phone (559) 365-2970/FAX (559) 846-9353 Clinica Sierra Vista – West Fresno 302 Fresno St., Suite #101 Fresno, CA 93706 Phone (559) 457-5700/FAX (559) 457-5790 Valley Health Team – Kerman 942 S. Madera Ave. Kerman, CA 93630 Phone (559) 364-2980/FAX (559) 846-9157 Clinica Sierra Vista – Gaston Middle School 1120 E. Church Ave. Fresno, CA 93706 Phone (559) 457-6970/FAX (559) 457-6695 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 – San Joaquin San Joaquin, CA 93660 Phone (559) 693-2462/Phone (559) 693-2467 FAX (559) 693-2398 Valley Health Team – Sablan 927 O St. Firebaugh, CA 93600 Phone (559) 659-3037/FAX (559) 659-3434 Valley Health Team – Clovis 180 W. Shaw Ave., Suite B Clovis, CA 93612 Phone (559) 203-6600/FAX (559) 326-5273 Adventist Health – Kerman Central 275 S. Madera#201 Kerman, CA 93630 Phone (559) 846-5240/FAX (559) 846-3787 Adventist Health – Lemoore East 810 East D St. Lemoore, CA 93245 Phone (559) 924-7711/FAX (559) 924-1658 Adventist Health – Fowler 119 Sixth St. Fowler, CA 93625 Phone (559) 834-1614/FAX (559) 834-0015 Adventist Health – Coalinga 155 S. Fifth St. Coalinga, CA 93210 Phone (559) 935-4282/FAX (559) 935-4285 Adventist Health – Orange Cove 1455 Park Ave. Orange Cove, CA 93646 Phone (559) 626-0882/FAX (559) 626-7498 Adventist Health – Parlier/Newmark 155 S. Newmark Ave. Parlier, CA 93648 Phone (559) 646-1200/FAX (559) 646-6622 Adventist Health – Sanger 1939 S. Academy Sanger, CA 93657 Phone (559) 887-6900/FAX (559) 875-6011 Adventist Health – Caruthers East 2357 W. Tahoe Caruthers, CA 93609 Phone (559) 864-5200/FAX (559) 864-8403 Adventist Health – Caruthers 2440 W. Tahoe Caruthers, CA 93609 Phone (559) 864-3212/FAX (559) 864-8510 27 Adventist Health – Reedley Cyprus 372 W. Cyprus Reedley, CA 93654 Phone (559) 626-0882/FAX (559) 643-8057 Adventist Health – Kingsburg 1251 Draper St. Kingsburg, CA 93631 Phone (559) 897-6610/FAX (559) 897-6611 Adventist Health – Huron 16916 Fifth St. Huron, CA 93234 Phone (559) 945-9090/FAX (559) 945-9100 Adventist Health – Reedley 1311 11th St. Reedley, CA 93654 Phone (559) 638-3227/FAX (559) 638-3799 Adventist Health – Riverdale 3567 Mt. Whitney Ave. Riverdale, CA 93656 Phone (559) 867-7200/FAX (559) 867-0152 Adventist Health – Selma Central 2141 High St., #E Selma, CA 93662 Phone (559) 891-2611/FAX (559) 891-2616 Adventist Health – Kerman 1000 S. Madera Kerman, CA 93630 Phone (559) 846-9370/FAX (559) 846-9352 Adventist Health – Selma Campus 1041 Rose Ave. Selma, CA 93662 Phone (559) 856-6090/FAX (559) 856-6092 Community Medical Centers – Emergency Department 2823 Fresno St. Phone (559) 459-3998/FAX (559) 459-7417 Community Medical Centers – Specialty Health Center 290 N. Wayte, 2nd Floor Fresno, CA 93701 Phone (559) 459-7300/FAX (559) 459-5040 Community Medical Centers – Internal Medicine 290 N. Wayte, 2nd Floor Fresno, CA 93701 Phone (559) 459-5721/FAX (559) 459-5097 Community Medical Centers – Family Health Center 290 N. Wayte, 2nd Floor Fresno, CA 93701 Phone (559) 459-5700/ FAX (559) 459-6109 Community Medical Centers 290 N. Wayte, 1nd Floor Fresno, CA 93701 Phone (559) 459-4300/FAX (559) 459-4555 Community Medical Centers – Women’s Health Center 290 N. Wayte, 1st Floor Fresno, CA 93701 Phone (559) 459-5755/FAX (559) 459-4454 28 EXHIBIT B ADMINISTRATOR shall process claims under this Restated Agreement from the following medical providers: Central California Ear Nose & Throat 1351 E. Spruce Ave. Fresno, CA 93720 Phone (559) 432-3303/FAX (559) 432-1468 California Eye Institute 1360 E. Herndon Fresno, CA 93720 Phone (559) 449-5000/FAX (559) 449-5044 Community Medical Centers 2823 Fresno Street Fresno, CA 93721 Phone (559) 459-6000 Community Medical Centers – Specialty Health Center 290 N. Wayte, 2nd Floor Fresno, CA 93701 Phone (559) 459-7300/FAX (559) 459-5040 Central California Faculty Medical Group 2625 E. Divisadero Fresno, CA 93721 Phone (559) 453-5200/FAX (559) 453-5233 Central California Faculty Medical Group Diana Johnson, Accounts Receivable Manager 2625 E. Divisadero Fresno, CA 93721 Phone (559) 453-5200 Ext. 292 Email: diana.johnson@ccfmg.org Pathology Associates 305 Park Creek Road Clovis, CA 93611 and/or PO Box 509015, Dept. WS206 San Diego, CA 92150 California Cancer Center 7257 N. Fresno Street Fresno, CA 93720 Phone (559) 477-4050 Clovis Community Medical Center 2755 Herndon Ave. Clovis, CA 93611 Phone (559) 324-4000 29 EXHIBIT C See attached Specialty Care Referral Form for Non-Resident Specialty Care. 30 EXHIBIT D The scope of services for Non-Resident Specialty Care 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 O. Radiology, including Computerized Tomography (CT) Scans and Magnetic Resonance Imaging (MRI) P. Laboratory Services Q. Pharmacy Services R. Urology 31 EXHIBIT E 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). 32 (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 Page 1 of 6 SPECIALTY CARE REFERRAL FORM Please submit this form to: 1. Date of Request:____/____/_____ 2. Date Client Last Seen by Requesting Physician:____/____/____ PATIENT INFORMATION 3. Patient Name: Last First Middle Date of Birth (Mo/Day/Yr): Age: Gender: M F 4. Address: Street City State Zip Code Phone Number: ( ) 5. Does patient have Restricted Medi-Cal? Yes No MEDS Aid Code: _____________________  If “Yes”, what is the patient’s BIC/CIN Number? ___________________________  If “No”, is the patient’s Medi-Cal application pending? Yes No Medi-Cal application date:_____________ REQUESTING CLINIC/HOSPITAL INFORMATION 6. Requesting Physician (please print): Tax ID #: Clinic Name: 7. Contact Person in Requesting Provider’s Office: Telephone #: ( ) Fax #: ( ) Name of PCP (if different than requesting physician): 8. Requesting Clinic/Hospital Address: Street City State Zip Code REFERRAL REQUESTED 9. ☐ Cardiology ☐ Dermatology ☐ Endocrinology ☐ Gastroenterology ☐ Inpatient Hospitalization ☐ Laboratory Services ☐ Neurology ☐ Gynecology ☐ Oncology ☐ Ophthalmology ☐ Oral/Maxillofacial ☐ Orthopedics ☐ Otolaryngology (ENT) ☐ Outpatient Surgery ☐ Pharmacy Services ☐ Pulmonology ☐ Urology ☐ Radiology, including Computerized Tomography (CT) Scans and Magnetic Resonance Imaging (MRI) CPT Codes:_________________________________________ Other:__________________________________________ CLINICAL INFORMATION 10. Medical Diagnosis ICD-10 Code Date of Onset month/year Advantek Benefit Administrators P.O. Box 1507, Fresno, CA 93716-1507 Attn: Dawn Dahl / FAX# (559) 228-4279 EXHIBIT C Page 2 of 6 11.Referring Physician Comments: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Client clinical data attached: Lab Reports: ☐ X-ray: ☐ Narrative Reports: ☐ Medication Report: ☐ ☐ Other: ________________________________________________________________________________________________ APPLICANT’S LANGUAGE PREFERENCE 12. I prefer to speak in the language checked below: Prefiero hablar el idioma indicado a continuación: English/Ingles ☐ Spanish/Español ☐ Other/Otro ☐ What language do you speak/Qué 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 información escrita: English/Ingles ☐ Spanish/Español ☐ Other/Otro ☐ What language do you read and write/En qué idioma usted lee y escribe:___________________ APPLICANT’S ATTESTATION (Sign one of the attestations below dependent upon language preference) 13.I, _________________________________, attest the following is true and correct under penalty and perjury under the laws of the State of California: (1) I am currently a resident of the 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 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 and that such services are dependent upon my continued eligibility and the availability of such funding. (Applicant’s Attestation continues on Page 3) EXHIBIT C Page 3 of 6 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 Santé Health System, d.b.a. Advantek Benefit Administrators, pertaining to the processing of this referral form and receipt of non- emergency specialty medical services. Applicant Signature: __________________________________________ Date: _________________ OR Yo, ________________________________, doy fe de que lo siguiente es verdadero y correcto bajo pena de perjurio en virtud de las leyes del estado de California: (1) actualmente resido en el condado de Fresno; (2) no poseo ingresos familiares que superen el 138 % del nivel de pobreza federal; (3) he solicitado beneficios de Medi-Cal integrales; y (4) he agotado todas las demás opciones de atención médica que tenía disponibles, lo que incluye a mero título enunciativo pagos por parte de terceros, tales como seguro privado, el Departamento de Asuntos de los Veteranos de los EE. UU., indemnización por accidente laboral, Medicare, a través de mi propio lugar de trabajo o el de mi cónyuge, a través de mis padres o tutores, o cobertura de seguro del propietario de vivienda o vehículo motorizado. Reconozco y entiendo que la presentación de este formulario de remisión tiene como único fin obtener los servicios de atención especializada necesarios y que no sean de emergencia enumerados en el presente y que esto depende únicamente de la disponibilidad de fondos para reembolsar a los proveedores médicos de atención especializada que pudieran prestar dichos servicios. Reconozco y comprendo que no tengo derecho legal a recibir servicios de atención especializada y que no sean de emergencia, y que dichos servicios dependen de mi elegibilidad continua y de la disponibilidad de dichos fondos. Asimismo, renuncio, libero y exonero para siempre cualesquiera reclamos o acciones, conocidos o desconocidos, que pudiera tener en contra del condado de Fresno y Santé Health System, que opera bajo el nombre de Advantek Benefit Administrators, en lo referido al procesamiento de este formulario de remisión y a la recepción de servicios médicos especializados que no sean de emergencia. Firma del solicitante: ____________________________________________ Fecha: ____________ EXHIBIT C Page 4 of 6 PHYSICIAN’S ATTESTATION (Sign one of the attestations below dependent upon patient care setting) REQUESTING PRIMARY CARE PHYSICIAN’S ATTESTATION 14. 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: ________________ EXHIBIT C Page 5 of 6 INSTRUCTIONS FOR COMPLETING THE SPECIALTY CARE REFERRAL FORM 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. If “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 of the patient’s primary care physician if the 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. EXHIBIT C Page 6 of 6 Clinical Information 10. Medical Diagnosis, ICD-10 Code, and Date of Onset: The Medical Diagnosis, ICD-10 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 of the 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.