5-APPENDIX G Behavioral Health Gross Receipt Tax Accountability Attestation.pdf
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- Solicitation number
- RFP 31-26-EM
- Issued by
- Bernalillo County, New Mexico
About this file
This is a Behavioral Health Gross Receipt Tax Accountability Attestation form required by Bernalillo County, New Mexico, in connection with the Intensive Case Management Services for Community Connections Supportive Housing program. The attestation serves as a compliance document for organizations seeking to contract with the County's Behavioral Health Authority Division to provide behavioral health services. Contractors must commit to using Gross Receipt Tax (GRT) funds exclusively for contracted services aimed at improving behavioral health indicators for eligible recipients within the County or other mutually agreed-upon locations. Organizations are required to participate in audits conducted by the Behavioral Health Authority Division to ensure appropriate utilization of GRT funds in accordance with the service agreement.
The attestation obligates contractors to coordinate with third-party payers and insurance providers, including commercial, Medicare, and Medicaid plans, by submitting appropriate claims and invoices for medically necessary services. Contractors must seek and maintain provider network participation with relevant third-party payers based on their client populations and comply with all applicable federal and state statutes and regulations governing claims submission. Organizations not currently contracted with Medicaid or other third-party payers must pursue credentialing and provider network participation within six months of submitting the attestation form. An authorized signatory must certify under oath that the organization's declarations are true, exact, and complete, with the form requiring the signatory's signature, title, and date of execution.
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Appendix G
Behavioral Health Gross Receipt Tax Accountability Attestation
On this __________ day of ______________, _______, I. ___________________________ authorize signatory attest that _________________________, dba, _________________________ desires to do business with Bernalillo County and will ensure to taxpayers in the County that GRT funds will be expended appropriately and declare upon oath that our organization:
A. Will not use revenue from its contract with the County for any other purpose than for contracted services to improve behavioral health indicators as identified by the service contract of eligible recipients within the County or other location(s) as specified by mutual agreement of the parties.
B. Agrees to participate in any audits to ensure that GRT funds are being utilized appropriately and in accordance with the service agreement and as approved by the Behavioral Health Authority Division.
Does not / Does (circle one) provide services that are eligible for reimbursement by insurance companies and/or other third-party payers and agrees to do the following as applicable:
a. Submit claims and/or invoices as appropriate to applicable third-party payers/insurance companies for medically necessary services provided to eligible and enrolled members or subscribers, which includes but is not limited to, individual or group coverage with commercial, Marketplace, Medicare, and/or Medicaid lines of business (including both fee-for-serve and Medicaid coverage provided by managed care organizations)
b. Submit claims and/or invoices to third-party payers/insurance companies according to all applicable federal and state statutes and regulations.
c. Will seek participation and remain in good standing in third-party payer/insurance companies’ provider networks as appropriate based on the majority of clients served in order to ensure that services provided are coordinated with other covered and medically necessary services received if may/our services are covered by third-party, e.g., Medicaid.
d. If not currently contracted, will seek provider network participation with the goal of being contracted with Medicaid and other third-party payers/insurance carriers as appropriate to my/out clientele and be credentialed as appropriate within six (6) months of receipt of this attestation form.
I attest that the preceding declaration is true, exact, and complete.
Authorized Signatory Signature and Title Date
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