E_-_Tribal_Use_of_FI_MOU.docx

MEMORANDUM OF AGREEMENT

BETWEEN

TRIBE AND THE INDIAN HEALTH SERVICE

This agreement sets forth the terms and conditions in regard to the Tribe utilizing the services of the Indian Health Service (IHS) Purchased/Referred Care (PRC) Program Fiscal Intermediary (FI) services.

I. Purpose

The purpose of this agreement between the Tribe and the IHS is to permit the Tribe, a tribal organization as defined and authorized under Public Law 93-638, as amended, to utilize the services of the FI.

II. Areas of Collaboration

The Tribe and the IHS have identified areas of common interest which bear upon this agreement including economies of scale, identification of alternate funding resources, manage care activities, and the maximization of purchasing power. The establishment of this relationship will greatly enhance the Tribe’s medical purchasing power. In addition, by including the Tribe’s workload in the utilization of the FI, the IHS gains stronger purchasing power with medical providers and the FI and gains access to the Tribe referral database. Further, this agreement may also serve as a model for other tribes or tribal organizations which may wish to utilize the FI contract.

III. Tribal Responsibilities

Under the terms of this agreement, the Tribe will:

1. Pay for the cost of utilizing the FI contract by continuing to leave its fiscal intermediary contract-related tribal shares with the IHS. The current annual value of the Tribe’s FI tribal shares is $ . The value of tribal shares related to the FI was determined by first dividing the total annual cost of the FI (approximately $14 million) by the total volume of all IHS claims processed by the FI during FY 1993. Then to determine each tribe’s and tribal organization’s share of the FI, the resultant cost per claim was multiplied by number of claims processed on behalf of each entity in FY 1993. This calculation determined the Tribe’s use of the FI to have a value of $ .

2. It is understood that the IHS may enter into a new contract for FI services during the term of this agreement. A new contract may result in a new value for the Tribe’s tribal share of that contract. However, the IHS will not seek any additional fee or reimbursement for the Tribe’s future use of the FI unless it can be demonstrated that the Tribe is requesting the FI to process at least 10% more claims annually than when the IHS last managed the PRC program for the Tribe.

3. Maintain a bank account for the FI to pay provider claims against and ensure funds are available to cover payments. Conditions for this bank account are contained in the Memorandum of Understanding (MOU) between the Tribe and the FI. A copy of the current MOU is attached for informational purposes only.

4. Under the conditions contained in the MOU, submit claims for payment to the FI.

5. Provide technical assistance to the FI as needed in regard to provider and payment issues of interest to the Tribe or the FI.

6. Establish a point of contact, listed herewith, to act as the representative for the Tribe to ensure compliance with the responsibilities described in this section. The Tribe’s point of contact is:

Name:

Title:

Department:

Address:

Telephone:

IV. IHS Responsibilities

Under the terms of this agreement, the IHS will:

1. Allow the Tribe to utilize the FI services as defined and described in the MOU between the Tribe and the FI, a copy of which attached for information purposes only.

2. Assist in the effective and efficient implementation of all aspects of this agreement.

3. Work with the Tribe and the FI to resolve provider payment issues related to services authorized by the Tribe.

4. Ensure that FI services are provided to the Tribe in consideration for the tribal shares retained by the IHS for such services.

5. Establish a point of contact, listed below, to act as the representative of the IHS to monitor compliance with the responsibilities described in this section. The IHS point of contact is:

Mr. Clayton Old Elk Fiscal Intermediary Project Officer Division of Contract Care Office of Resource Access and Partnerships Indian Health Service 801 Thompson Avenue, Suite 360 Rockville, MD 20852 Telephone: (301) 443-2694

V. Authority

This agreement is made under the authority of Section 17003 of the Consolidated Omnibus Budget Reconciliation Act of 1985.

VI. Resources

1. The IHS agrees to provide: Access to the FI services for the Tribe.

2. The Tribe agrees to provide: Financial support for its use of the FI in the form of tribal shares left with the IHS (“Retained Tribal Shares”) in consideration for the fiscal intermediary services provided by the FI. If the annual claim volume exceeds the demonstrated FY98 Tribal claim volume by 10% or more, the Tribe will reimburse the IHS on an actual cost per claim basis for the number of claims in excess of the 10%. The cost will be determined by dividing the published annual FI contract cost by the total volume of claims covered by the IHS/FI contract for the year in question. The processing year will be for claims processed from January 1st of a given year through the following eighteen (18) months (June 30th of the second year following). Such reimbursement will be by lump sum no later than 30 days from billing by the IHS.

VII. Amendments

This agreement, or any of its specific provisions, may be revised by signature approval by both parties.

VIII. Duration of Agreement:

This agreement shall be effective upon date of signature and remain in effect through DATE . Unless modified in writing by mutual agreement, or terminated by either party upon 30 days written notice, it will automatically renew annually thereafter.

In the event that the FI services are not provided to the Tribe or the IHS, as specified in this agreement or as agreed to in the MOU referred to elsewhere in this document, neither the Tribe nor the IHS will be under any obligation to undertake or complete the work described in this agreement or the MOU.

IX. Hold Harmless Clause:

The Tribe is responsible for payment of all services authorized and or ordered by the Tribe, its officials and its employees through tribal purchase delivery orders or any other means. The IHS bears no financial responsibility other than described in Sections III. 1 and VI. 2 under this agreement. Except for making available to the Tribe the unused portion of the tribal shares in support of the FI, the IHS bears no legal obligation for any failure by the FI to provide services to the Tribe.

X. Approval:

FOR: INDIAN HEALTH SERVICE FOR: TRIBE

BY: _________________________ BY: _________________________

Director Title Indian Health Service

DATE: _________________________ DATE: _________________________