Washington > Statewide > Department Of Social And Health Services
Core Provider Agreement DSHS 09-048 - Washington
| Core Provider Agreement Form. This is a Washington form and can be used in Department Of Social And Health Services Statewide . |
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CORE PROVIDER AGREEMENT The Department of Social and Health Services (the department) administers medical assistance and medical care programs for eligible clients. The department provides medical assistance or medical care to certain eligible clients by enrolling eligible providers of medical services. The department reimburses enrolled eligible providers for covered medical services, equipment, and supplies they provide to eligible clients. To be eligible for enrollment, a provider must: a. b. c. d. Complete the attached enrollment application; Be an eligible provider and meet the conditions contained in WAC 388-502-0010; Complete and sign a debarment form; and Meet all the applicable state and/or federal licensure requirements to assure the department of his/her qualifications to perform services under this Agreement. This includes maintaining professional licensure in good standing without any stipulation in the provider's license. A provider will be considered a participating provider once the provider completes the above requirements and signs this Agreement, the department issues a provider number, and the provider bills and accepts payment from the department. As a participating provider in the medical assistance and medical care programs, hereafter known as Provider, the Provider agrees to the following: 1. Governing Law and Venue. This Agreement shall be governed by the laws of the State of Washington. In the event of a lawsuit involving this Agreement, venue shall be proper only in Thurston County, Washington. The medical assistance and medical care programs are authorized and governed by Title XIX of the Social Security Act, Title XXI of the Social Security Act, Chapter IV of Title 42 of the Code of Federal Regulations, Chapter 74.09 of the Revised Code of Washington, and Title 388 of the Washington Administrative Code. The Provider is subject to and shall comply with all federal and state laws, rules, and regulations and all program policy provisions, including department numbered memoranda, billing instructions, and other associated written department issuances in effect at the time the service is rendered, which are incorporated into this Agreement by this reference. 2. License. The Provider shall be licensed, certified, or registered as required by State and/or Federal law. The Provider will notify the Department within seven (7) days of learning of any adverse action initiated against the license, certification, or registration of the Provider or any of its officers, agents, or employees. 3. Billing and Payment. The Provider agrees: a. To submit claims for services rendered to eligible clients, as identified by the department, in accordance with rules and billing instructions in effect at the time the service is rendered. b. To accept as sole and complete remuneration the amount paid in accordance with the reimbursement rate for services covered under the program, except where payment by the client is authorized by applicable WAC. In no event shall the department be responsible, either directly or indirectly, to any subcontractor or any other party that may provide services. c. To be held to all the terms of this Agreement even though a third party may be involved in billing claims to the department. It is a breach of this Agreement to discount client accounts (factor) to a third party biller or to pay a third party biller a percentage of the amount collected. 4. Disclosure. The Provider agrees to submit full and complete disclosure on the enrollment application the following: DSHS 09-048 (REV. 10/2008) American LegalNet, Inc. www.FormsWorkFlow.com 1 a. Ownership and control information as required by 42 Code of Federal Regulations, parts 455.100 through 455.106; b. Identity of any person who has ownership or control interests in the Provider, or is an agent or managing employee of the Provider who has been convicted of any felony and/or convicted of a criminal offense (felony or misdemeanor) relating to program crimes as required by 42 Code of Federal Regulations, part 455.106; and c. Any denial, termination, or lack of professional liability coverage, or any change in professional liability coverage, including restrictions, modifications, or discontinuing coverage. At any time during the course of this Agreement, the Provider agrees to notify the department of any material and/or substantial changes in information contained on the enrollment application given to the department by the Provider. This notification must be made in writing within thirty (30) days of the event triggering the reporting obligation. Material and/or substantial changes include, but are not limited to changes in: a. b. c. d. e. Ownership; Licensure; Federal tax identification number; Additions, deletions, or replacements in group membership; and Any change in address or telephone number. 5. Inspection; Maintenance of Records. For six (6) years from the date of services, or longer if required specifically by law, the Provider shall: a. Keep complete and accurate medical and fiscal records that fully justify and disclose the extent of the services or items furnished and claims submitted to the department. b. The Provider shall make available upon request appropriate documentation, including client records, supporting material, and any information regarding payments claimed by the Provider, for review by the professional staff within the department or the Secretary of the U.S. Department of Health and Human Services. The Provider understands that failure to submit or failure to retain adequate documentation for services billed to the department may result in recovery of payments for medical services not adequately documented, and may result in the termination or suspension of the Provider from participation in the medical assistance and medical care programs. 6. Audit or Investigation. Audits or investigation may be conducted to determine compliance with the rules and regulations of the program. If an audit or investigation is initiated, the Provider shall retain all original records and supportive materials until the audit is completed and all issues are resolved even if the period of retention extends beyond the required 6 year period. 7. Disputes. Either party who has a dispute concerning this Agreement may request an administrative review hearing in accordance with applicable WAC. 8. Termination. The department shall deny, suspend, or terminate the Provider's enrollment for cause acco
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