Attachment C2.pdf

AGREEMENT FOR PSYCHIATRIC INPATIENT HOSPITAL SERVICES BETWEEN THE COUNTY OF SANTA CLARA AND

[CONTRACTOR NAME] FOR FISCAL YEAR 20xx

AGREEMENT FOR ACUTE PSYCHIATRIC INPATIENT HOSPITAL SERVICES

BETWEEN THE COUNTY OF SANTA CLARA AND [CONTRACTOR NAME] FOR FISCAL

YEAR 20XX

This is an agreement (AGREEMENT) between the County of Santa Clara (COUNTY) and [Contractor

Name], a [non-profit] OR [for-profit] corporation, (CONTRACTOR), for the provision of Psychiatric

Inpatient Hospital Services

RECITALS

Pursuant to certain federal statutes and state statutes, including section 14712, et seq. of the California

Welfare and Institutions Code (WIC) and the regulations promulgated thereunder, agreements between the State of California and COUNTY, and certain approvals granted by the Secretary of the United

States Department of Health and Human Services through the Centers for Medicare and Medicaid

Services (formerly known as Health Care Financing Administration [HCFA]), COUNTY is authorized to contract for provision of Psychiatric Inpatient Hospital Services (as that term is defined in

Appendix A and below) to Medi-Cal beneficiaries (herein “Beneficiaries,” as defined in Appendix A) in accordance with the rates, terms, and conditions negotiated by COUNTY.

CONTRACTOR operates a general acute care hospital with an approved psychiatric unit located at

[Facility name and address] (Facility), which presently provides Psychiatric Inpatient Hospital

Services.

The definitions applicable to this AGREEMENT are contained in Appendix A, which is incorporated by this reference.

AGREEMENT

IN CONSIDERATION of the foregoing recitals and the covenants and conditions hereinafter expressed, the parties hereby agree as follows:

ARTICLE 1

PERFORMANCE PROVISIONS

1.1 General Agreement

(a) CONTRACTOR agrees to provide Psychiatric Inpatient Services (services) within the scope of its licensure to Beneficiaries in need of such services, and agrees to accept payment from COUNTY as payment in full for such services as set forth in this

AGREEMENT and the following Exhibits and Appendices attached hereto and incorporated herein:

Exhibit (FYxx) B Program Rates

Appendix A Definitions

Appendix B Insurance Requirements for Professional Services

ATTACHMENT C2

Sam ple

[CONTRACTOR NAME] FOR FISCAL YEAR 20xx

(b) COUNTY agrees to pay CONTRACTOR as set forth in Article 2. CONTRACTOR’s obligations hereunder will include, but will not be limited to, the following:

(1) CONTRACTOR will, at its own expense, provide and maintain space, utilities, equipment and furniture at the Facility as may be necessary to provide services, and to clean and maintain such space, utilities, equipment and furniture in good order and repair.

(2) CONTRACTOR will retain, at its own expense, all such professional, allied and supportive paramedical personnel as may be reasonably necessary and appropriate to provide services.

(3) CONTRACTOR will, at its own expense, provide and maintain the organizational and administrative capabilities to carry out its duties and responsibilities under this AGREEMENT and all applicable statutes and regulations pertaining to Medi-Cal providers.

(4) CONTRACTOR will provide services within the scope of CONTRACTOR's licensure to all Beneficiaries who are referred to CONTRACTOR by COUNTY, unless compelling clinical or operational circumstances exist that contraindicate admission.

(5) CONTRACTOR agrees to obtain consent to treat each Beneficiary in a specific form or format pursuant to California Welfare and Institutions Code Section

5326.2 or any other applicable statute or regulation.

(6) CONTRACTOR will refer Beneficiaries for other services when necessary.

(c) Public Health Emergency or Other Emergency Disaster Plan

(1) CONTRACTOR shall have policies and procedures to address disaster preparedness during a Public Health Emergency or other emergency disaster.

(i) Subject to applicable guidance and other directives, CONTRACTOR will be expected to continue to deliver services during a Public

Health Emergency or other emergency disaster, including, but not limited to a pandemic such as the COVID-19 pandemic.

(ii) CONTRACTOR shall develop and implement protocols and procedures based on the guidance of appropriate agencies, such as the County Health Officer, Centers for Disease Control and

Prevention (CDC), Federal Emergency Management Agency

(FEMA), or others, as applicable.

(iii) CONTRACTOR shall develop an emergency and disaster plan that includes at a minimum, evacuation procedures, training for workforce members, and quarterly emergency drills. The emergency and disaster plan shall be readily available for staff during an emergency and shall be reviewed and updated as necessary on a regular basis.

(iv) CONTRACTOR shall follow the protocols and procedures to protect staff and clients for service delivery during a Public Health

Emergency or other emergency disaster, including but not limited to a pandemic such as the COVID-19 pandemic.

1.2 Licensure and Certification as Conditions Precedent to County’s Payment Obligation

(a) CONTRACTOR hereby represents and warrants that it is currently, and for the duration of this AGREEMENT will and agrees to remain:

(1) A “PSYCHIATRIC INPATIENT HOSPITAL ,” which means a health facility licensed by the Department that provides 24-hour inpatient care for people with mental health disorders or other persons described in Division 5 (commencing with Section 5000) or Division 6 (commencing with Section 6000) of the

Welfare and Institutions Code and subject to the provisions in Chapter 9, Division 5 of Title 22 of the California Code of Regulations. For the purposes of this chapter, psychiatric health facilities that have been certified by the

Department as Medi-Cal providers of inpatient hospital services will be governed by the provisions applicable to hospitals and psychiatric inpatient hospital services, except when specifically indicated in context.

(2) A facility accredited by the Joint Commission.

(3) Certified to participate in the Medicare program under Title XVIII of the federal

Social Security Act.

(4) In compliance with all federal Medicaid laws, regulations and guidelines and all applicable Federal and State laws and regulations.

(5) A party to a Medi-Cal provider agreement with the Department of Health Care

Services (DHCS).

(b) CONTRACTOR agrees that compliance with the conditions set forth above will be express conditions precedent to COUNTY's payment obligations under Paragraph 1.3

(a) and Article 2 of this AGREEMENT.

(c) CONTRACTOR will comply with all applicable laws, regulations, and rules relating to the provision of medical and health care services that now exist or are hereinafter modified or adopted, including, without limitation, all permits, licenses, governmental and board approvals. CONTRACTOR agrees that it will maintain Joint Commission accreditation throughout the term of this AGREEMENT. CONTRACTOR agrees to give COUNTY immediate notice of any proceeding that jeopardizes its Joint

Commission accreditation. This provision is a material term of this AGREEMENT, the breach of which will constitute cause for immediate termination of this AGREEMENT.

1.3 Utilization Controls: Compliance by Contractor as Condition Precedent to County's Payment

Obligation

(a) As express conditions precedent to COUNTY's payment obligation under the terms of this AGREEMENT, CONTRACTOR will adhere to COUNTY's Quality Management

Plan including utilization controls (COUNTY’s Inpatient Provider Manual, January

2002: pages 4 and 5), to California Department of Mental Health Letters and Notices, as well as any requirements imposed on COUNTY pursuant to Sections 5777, subdivision

(g), and 5778, subdivision (n), of the California Welfare and Institutions Code and the implementing Regulations, as well as any other applicable state or federal law governing services rendered under the Medi-Cal program.

(b) CONTRACTOR will comply with existing federal requirements for utilization review pursuant to Title 42, 456.180, Code of Federal Regulations, Part 456, Subpart D, including but not limited to certification of need for care, evaluation and medical review, plans of care and utilization review plan.

(c) CONTRACTOR will comply with the COUNTY Policies, Procedures, and directives, as applicable.

1.4 Appointment of Liaison

CONTRACTOR will designate, in writing, a person to act as liaison to the COUNTY. Such person will coordinate all communications between the parties. The written designation of such person will constitute the conferral of full agency powers to bind CONTRACTOR as principal in all dealings with COUNTY to the extent that such dealings relate to this

AGREEMENT and/or CONTRACTOR's provision of services.

1.5 Service Location

Psychiatric Inpatient Hospital Services rendered pursuant to this AGREEMENT will be rendered at the Facility, unless approved by COUNTY.

1.6 Quality of Care

(a) As express conditions precedent to COUNTY payment obligation under the terms of this AGREEMENT, CONTRACTOR will:

(1) Assure that any and all Beneficiaries receive culturally competent services and age-appropriate care as required by the Regulations and are consistent with

COUNTY's Quality Management Plan and the COUNTY’s Cultural

Competency Plan.

(2) Take such action as required by CONTRACTOR's Medical Staff Bylaws against medical staff members who violate such Bylaws, as the same may be from time to time amended.

(3) Provide services in the same manner to Beneficiaries as it provides to all patients to whom it renders Psychiatric Inpatient Hospital Services or similar hospital services.

(4) Not discriminate against Beneficiaries in any manner, including admission practices, placement in special or separate wings or rooms, or provision of special or separate meals.

1.7 Assumption of Risk by Contractor

CONTRACTOR will bear total risk for the cost of Psychiatric Inpatient Hospital Services rendered to each Beneficiary covered by this AGREEMENT. As used in this Paragraph, "risk" means that CONTRACTOR agrees to accept as payment in full for any and all Psychiatric

Inpatient Hospital Services payments made by the or COUNTY pursuant to Article 2 of this

AGREEMENT, irrespective of whether the cost of such services and related administrative expenses will have exceeded the payment obligation of COUNTY under the conditions set forth in this AGREEMENT. The term "risk” also includes, but is not limited to, the cost for all

Psychiatric Inpatient Hospital Services for illness or injury resulting, in whole or in part, from a catastrophe or disaster which occurs subsequent to the Effective Date (as defined in Section 4.1 below), including but not limited to acts of God, war or the public enemy.

1.8 Patient Rights

(a) CONTRACTOR or any Delegate providing services pursuant to the terms of this

AGREEMENT will adopt and post in a conspicuous place a written policy on patient's rights in accordance with section 70707 of Title 22 of the California Code of

Regulations and section 5325 et seq. of the California Welfare and Institutions Code.

All complaints by Beneficiaries with regard to services provided hereunder may be investigated by COUNTY's Patient Rights Advocate, COUNTY, California Department of Mental Health, by the Joint Commission on Accreditation of Health Care

Organization, or such other agency, as required or permitted by law or regulations.

(b) CONTRACTOR will maintain throughout the term of this AGREEMENT a process for the resolution of Beneficiary complaints and grievances. CONTRACTOR agrees to cooperate with COUNTY with respect to the complaint resolution and grievance process maintained by COUNTY pursuant to the Regulations.

1.9 Consultation Requirements Regarding Adults on the Adolescent Unit

(a) CONTRACTOR will notify COUNTY Behavioral Health Services Director, or designee, if:

(1) A patient 18 years of age or older is admitted to the Adolescent Unit while a

Santa Clara County patient is also in the Adolescent Unit, or

(2) A Santa Clara County patient 18 years of age or older is to be admitted to the

Adolescent Unit.

1.10 Medi-Cal Rules

(a) CONTRACTOR must comply with all laws and regulations governing the Medi-Cal and

Medicaid programs imposed by federal, state, and local statutes, regulations, and rules governing certification, participation, coverage, and reimbursement including, but not limited to applicable provisions of the following:

(1) California Welfare and Institutions Code section 5600, et seq. (Short-

Doyle/Bronzan-McCorquodale Acts)

(2) Titles 9 and 22 of the California Code of Regulations

(3) Title XIX of the Social Security Act, and any applicable regulations promulgated thereunder

(4) Title VI of the Civil Rights Act (CRA) of 1964

(5) The Age Discrimination Act of 1975

(6) The Rehabilitation Act of 1973

(7) Title IX of the Education Amendments of 1972

(8) The Americans with Disabilities Act

(9) Section 1557 of the Patient Protection and Affordable Care Act (ACA)

(10) CONTRACTOR is required to comply with any applicable federal and state laws that pertain to enrollee rights and ensure that its employees and contracted providers observe and protect those rights.

(11) CONTRACTOR shall comply with all applicable Medicaid laws, regulations, including applicable subregulatory guidance and contract provisions.

(12) CONTRACTOR shall comply with all applicable laws and regulations relating to patients’ rights, including but not limited to, Welfare and Institution Code Section

5325 and 42 Code of Federal Regulations (C.F.R.) Section 438.100.

CONTRACTOR shall ensure its subcontractors comply with these provisions.

(13) As a condition for receiving payment under a Medi-Cal managed care program, CONTRACTOR shall comply with the provisions of 42 C.F.R. sections 438.604, 438.606, 438.608, and 438.610.

(14) Network Adequacy Standards

(v) CONTRACTOR shall meet the state standards for timely access to care and services, taking into account the urgency of need for services. CONTRACTOR shall offer hours of operation that are no less than the hours offered to commercial enrollees or that are comparable to Medicaid Fee-For-Service (FFS), if the provider serves only Medicaid enrollees. CONTRACTOR shall make services available twenty-four (24) hours a day, seven (7) days a week, when medically necessary.

(vi) CONTRACTOR shall establish mechanisms to ensure that it complies with the timely access requirements and shall monitor staff and services regularly to determine compliance with the timely access requirements. CONTRACTOR shall take corrective action if there is a failure to comply with the timely access requirements according to 42 C.F.R. Section 438.206(c)(1)(i)-(vi).

(vii) CONTRACTOR shall ensure the provision of physical access, reasonable accommodations, and accessible equipment for Medicaid enrollees with physical or mental disabilities according to 42 C.F.R.

Section 438.203(c)(3).

(15) For all services that CONTRACTOR is required to provide to adults, each service must be furnished in an amount, duration, and scope that is no less than the amount, duration and scope for the same services provided under FFS

Medicaid. CONTRACTOR must provide the same extent of services to enrollees under the age of twenty-one (21) as furnished to individuals under the age of twenty-one (21) under FFS Medicaid. CONTRACTOR is prohibited from arbitrarily denying or reducing the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition of the enrollee.

(16) CONTRACTOR is required to share the result of any identification and assessment of enrollee’s needs to prevent duplication of those activities with the

State or other Managed Care Organizations (MCO), Prepaid Inpatient Health

Plans (PIHP), and Prepaid Ambulatory Health Plans (PAHP) serving that enrollee.

1.11 Other Applicable Laws

CONTRACTOR will provide services under this AGREEMENT in accordance with all other applicable federal, state, and local laws, rules, regulations, policies, and codes, including BHSD Policies and Procedures, effective at the inception of this AGREEMENT and that become effective during the TERM of this AGREEMENT.

1.12 Notifications

(a) Within a reasonable time after receiving notice of Beneficiary’s enrollment, CONTRACTOR and its subcontractors shall inform Beneficiaries about:

(1) Beneficiary grievance, appeal, and fair hearing procedures and timeframes as specified in 42 C.F.R. Section 438.400 through 42 C.F.R. Section

438.424.

(2) The Beneficiary’s right to file grievances and appeals and the requirements and timeframes for filing.

(3) The availability of assistance to the Beneficiary with filing grievances and appeals.

(4) The Beneficiary’s right to request a State fair hearing after the COUNTY has made a determination on an enrollee's appeal, which is adverse to the

Beneficiary.

(5) The Beneficiary’s right to request continuation of benefits that the

COUNTY seeks to reduce or terminate during an appeal or state fair hearing filing, if filed within the allowable timeframes, although the

Beneficiary may be liable for the cost of any continued benefits while the appeal or state fair hearing is pending if the final decision is adverse to the

Beneficiary.

1.13 Credentialing Requirement. CONTRACTOR shall ensure that all of CONTRACTOR’s

Practitioners are credentialed/re-credentialed as required by law and as required by the

COUNTY for the services under this Agreement, through Valley Health Plan, the COUNTY’s designated Managed Services Organization (MSO) entity. CONTRACTOR shall ensure that staff comply in a timely manner with requests for Council for Affordable Quality Healthcare

(CAQH) ProView applications, and other relevant applications to ensure credentialing is completed prior to initiation of services. CONTRACTOR shall ensure that none of

CONTRACTOR’s Practitioners or staff provide services under this AGREEMENT until after each Practitioner’s/staff’s credentialing/re-credentialing process through Valley Health Plan is complete. CONTRACTOR shall provide COUNTY (BHSD and VHP) with an updated credentialed staff list on a monthly basis at minimum.

1.14 Medi-Cal Certification

CONTRACTOR will establish and maintain certification through COUNTY to provide

Medi-Cal reimbursable services (“Medi-Cal Certification”) before providing and billing for Medi-Cal services to clients. CONTRACTOR will not be reimbursed by COUNTY for any Medi-Cal services rendered prior to certification.

1.15 Disclosure of Violations and Unusual Incidents

(a) CONTRACTOR will notify COUNTY by telephone of any potential violations of any provision of this AGREEMENT and unusual incidents within twenty-four (24) hours of the occurred incident. In addition, a written notice must be sent to the

Director of BHSD within seventy-two (72) hours from the occurred incident.

(b) CONTRACTOR will comply with COUNTY policies, procedures, and requirements concerning the reporting of unusual occurrences and incidents.

(1) CONTRACTOR will provide COUNTY information and records about or related to: (a) complaints, grievances, appeals, and state fair hearings referenced in Section 1.12 of this Agreement; (b) violations, unusual incidents, fraud, waste, and abuse referenced in Section 1.14 (c) of this

Agreement; and (c) claims, litigation, or administrative proceedings commenced against COUNTY arising from CONTRACTOR’s, or its employees’, agents’, or subcontractors’, performance under this Agreement.

CONTRACTOR shall cooperate and assist COUNTY in COUNTY’s investigation of all such incidents listed in this subsection 1.14 (b)(1) of this

Agreement.

(2) CONTRACTOR shall notify COUNTY within forty-eight (48) hours of any litigation or administrative proceedings commenced against

CONTRACTOR or its agents or subcontractors arising from

CONTRACTOR’s, or its employees’, agents’, or subcontractors’ performance under this Agreement.

(c) CONTRACTOR must report potential fraud, waste, and abuse information to the

COUNTY. CONTRACTOR shall implement and maintain arrangements or procedures designed to detect and prevent fraud, waste, and abuse that include prompt reporting to the COUNTY about the following:

(1) Any potential fraud, waste, or abuse.

(2) All overpayments identified or recovered, specifying the overpayments due to potential fraud.

(3) Information about changes in a Beneficiary’s circumstances that may affect the Beneficiary’s eligibility including changes in the Beneficiary’s residence or the death of Beneficiary.

(4) Services Verification.

(d) In the event, and annually thereafter and upon request, that any person obtains an interest of five percent (5%) or more of any mortgage, deed of trust, note, or other obligation secured by CONTRACTOR, and that interest equals at least five percent

(5%) of CONTRACTOR’s property or assets, CONTRACTOR will make the disclosures set forth in the section below:

(1) The name and address of any person (individual or corporation) with an ownership or control interest in the CONTRACTOR’s network provider.

The address for corporate entities shall include, as applicable, a primary business address, every business location, and a P.O. Box address;

(2) Date of birth and Social Security Number (in the case of an individual);

(3) Other tax identification number (in the case of a corporation with an ownership or control interest in the managed care entity or in any subcontractor in which the managed care entity has a five percent (5%)or more interest);

(4) Whether the person (individual or corporation) with an ownership or control interest in the CONTRACTOR’s network provider is related to another person with ownership or control interest in the same or any other network provider of the CONTRACTOR as a spouse, parent, child, or sibling; or whether the person (individual or corporation) with an ownership or control interest in any subcontractor in which the managed care entity has a five percent (5%) or more interest is related to another person with ownership or control interest in the managed care entity as a spouse, parent, child, or sibling;

(5) The name of any other disclosing entity in which the CONTRACTOR or subcontracting network provider has an ownership or control interest; and

(6) The name, address, date of birth, and Social Security Number of any managing employee of the CONTRACTOR’s organization.

(e) CONTRACTOR must submit disclosures and updated disclosures to the COUNTY including information regarding certain business transactions within thirty-five (35) days, upon request. The following information must be disclosed:

(1) The ownership of any subcontractor with whom the CONTRACTOR has had business transactions totaling more than twenty-five thousand dollars

($25,000) during the twelve (12) month period ending on the date of the request; and

(2) Any significant business transactions between the CONTRACTOR and any wholly owned supplier, or between CONTRACTOR and any subcontractor, during the five (5) year period ending on the date of the request.

(3) CONTRACTOR must obligate network providers to submit the same disclosures regarding network providers within thirty-five (35) days upon request.

(f) CONTRACTOR shall submit the following disclosures to the COUNTY regarding the CONTRACTOR’s management:

(1) The identity of any person who is a managing employee of

CONTRACTOR who has been convicted of a crime related to federal health care programs according to 42 C.F.R. Section 455.106(a)(1)-(2).

(2) The identity of any person who is an agent of the CONTRACTOR who has been convicted of a crime related to federal health care programs. (42

C.F.R. Section 455.106(a)(1), (2).) For this purpose, the word "agent" has the meaning described in 42 C.F.R. Section 455.101.

(3) CONTRACTOR supply the disclosures before entering into the contract and at any time upon the COUNTY’s request.

ARTICLE 2

PAYMENT PROVISIONS

2.1 Rate Inclusive of All Psychiatric Inpatient Hospital Services; Rate Does Not Include, Transportation Services for Medi-Cal Beneficiaries, or Unsponsored Patients

The rates set forth in Paragraph 2.1 of this AGREEMENT for Medi-Cal Beneficiaries or

Unsponsored Patients are inclusive of all Psychiatric Inpatient Hospital Services including routine services and all facility-based ancillary services (as those terms are defined in the

Regulations), but do not include transportation services (CCR Title 9, Chapter 11, section

1810.355 (a) (1)(B)) required in providing Psychiatric Inpatient Hospital Services, and such transportation services will not be paid for or reimbursed by COUNTY under this

AGREEMENT. For transportation to Facility from Santa Clara Valley Medical Center, Emergency Psychiatric Services Unit, the COUNTY will reimburse the contracted transportation provider selected by the COUNTY for unsponsored Santa Clara COUNTY

Beneficiaries only. For Medi-Cal and other third-party payor patients discharging into a locked setting, transportation providers will bill Medi-Cal or third-party payor directly. For Santa

Clara COUNTY unsponsored Beneficiaries, authorized by the COUNTY, discharging into a locked setting or the community, the COUNTY will coordinate transportation and will pay the

COUNTY contracted transportation provider directly. For transportation as permitted under this paragraph, the CONTRACTOR will contact the COUNTY’s 24-Hour Care Unit to arrange transportation through the following telephone number: 1 (408) 885-7580. The 24-Hour Care

Unit is located at 2221 Enborg Lane, San Jose, CA 95128.

2.2 Billing Procedures as Express Conditions Precedent to County’s Payment Obligation

(a) As an express condition precedent to COUNTY's payment obligation under Paragraph

2.1 of this AGREEMENT, CONTRACTOR will use its best effort to determine whether

Psychiatric Inpatient Hospital Services rendered hereunder are covered, in whole or in part, under any other state or federal medical care program or under any other contractual or legal entitlement, including, but not limited to, a private group indemnification or insurance program or workers' compensation (herein, Third Party

Payors).

(b) As a further express condition precedent to COUNTY's payment obligation under

Section 2.1 of this Agreement, CONTRACTOR will bill its Customary Charges (as defined in the Regulations) and submit claims to the Fiscal Intermediary for all

Psychiatric Inpatient Hospital Services hereunder rendered in accordance with the applicable billing requirements contained in Section 5778 of the California Welfare and

Institutions Code and the Regulations, using the number assigned by the Medi-Cal program to CONTRACTOR and using the Allowable Psychiatric Accommodation

Codes set forth in the Regulations.

(c) A Day of Service will be billed for each Beneficiary who meets admission and/or continued stay criteria, documentation requirements, treatment and discharge planning requirements and occupies a psychiatric inpatient hospital bed at 12:00 midnight in the

Facility and for which the appropriate authorization has been granted, excluding the day of discharge. Day of discharge, while not reimbursed, shall be counted among the guaranteed number of dedicated beds. CONTRACTOR will be reimbursed for the vacant dedicated bed on day of discharge if census falls below the guaranteed number of dedicated beds.

(d) CONTRACTOR will bill any Third Party Payor financially responsible for a

Beneficiary's health care services. COUNTY accepts no financial responsibility for services provided to Beneficiaries where there is a responsible Third Party Payor, and to the extent that COUNTY inadvertently makes payment to CONTRACTOR for such services rendered, COUNTY will be entitled to recoup such reimbursement.

(e) In regards to Medi-Cal patients for whom Third Party Payors have financial responsibility, the COUNTY will approve reimbursement to CONTRACTOR at its per diem rates as set forth in Paragraph 2.1 less the net of liability of Third Party Payors and patient share of costs. COUNTY will not be responsible to provide or arrange and, pay for acute inpatient mental health services provided to a Beneficiary eligible for

Medicare, prior to the exhaustion of Beneficiary’s Medicare mental health benefits.

(f) Non-Payment to Entity/Provider

Pursuant to Title 9, CCR, Section 1810.365, the CONTRACTOR or an affiliate, vendor, CONTRACTOR, or sub-subcontractor of the CONTRACTOR will not submit a claim to demand or otherwise collect reimbursement from, the Beneficiary or persons acting on behalf of the Beneficiary for any specialty mental health or related administrative services provided under this AGREEMENT except to collect other health insurance coverage, share of cost and co-payments. The CONTRACTOR or an affiliate, vendor, CONTRACTOR, or sub-subcontractor of the CONTRACTOR will not hold

Beneficiaries liable for debts in the event that the CONTRACTOR becomes insolvent, for costs of covered services for which the State does not pay the CONTRACTOR, for costs of covered services for which the State or the CONTRACTOR does not pay the

CONTRACTOR’s providers, for costs of covered services provided under a contract, referral or other arrangement rather than from the CONTRACTOR, or for payment of subsequent screening and treatment needed to diagnose the specific condition of or stabilize a Beneficiary with an emergency psychiatric condition.

2.4 Recovery of Overpayment to Contractor, Liability for Interest

(a) When an audit or review performed by the COUNTY, the California Department of

Health Care Services (DHCS), the California Controller's Office, or any other authorized agency discloses that CONTRACTOR has been overpaid under this

AGREEMENT, or that the total payments exceed the total liability under this

AGREEMENT, CONTRACTOR covenants that any such overpayment or excess payments over liability may be recouped by the COUNTY withholding the amount due from future payments hereunder, by seeking recovery by payment from

CONTRACTOR, or a combination of these two methods. COUNTY agrees to send

CONTRACTOR a letter of explanation prior to time payment is withheld.

(b) Overpayments determined as a result of audits of periods prior to the effective date of this AGREEMENT may be recouped by the COUNTY withholding the amount due from what would otherwise be the COUNTY's liability under this AGREEMENT, by seeking recovery by payment from CONTRACTOR, or a combination of those two (2) methods.

(c) When recoupment or recovery is sought under 2.4(a), CONTRACTOR may appeal according to applicable procedural requirements of the Regulations and the regulations promulgated under Section 14680, et seq. of California Welfare and Institutions Code, except that the recovery or recoupment will commence sixty (60) days after issuance of account status or demand resulting from an audit or review and will not be deferred by the filing of an appeal in accordance with the applicable regulations.

(d) CONTRACTOR will be liable to COUNTY for the amount of any federal audit exceptions, disallowances, any sanctions, or withholding of funds of the Department or by DHCS as provided in Sections 5778 Subdivision (h), and 5779 Subdivision (e), of the Welfare and Institutions Code and the Regulations, to the extent that such exceptions, disallowances, sanctions, or withholding of funds relate to services rendered under this AGREEMENT.

(e) CONTRACTOR shall report and refund to the COUNTY any overpayments within sixty (60) calendar days of when it has identified the overpayment. CONTRACTOR shall implement and maintain arrangements or procedures that include provision for the suspension of payments to a network provider for which the State or COUNTY determines there is a credible allegation of fraud. CONTRACTOR shall specify the reimbursement policies for the treatment of recoveries of all overpayments, including specifically the retention policies for the treatment of recoveries of overpayments due to fraud, waste, or abuse or incorrect billing practices pursuant to the False Claims Act.

The policy shall specify the process, timeframes, and documentation required for payment of recoveries of overpayments to the State or COUNTY in situations where the

CONTRACTOR is not permitted to retain some or all of the recoveries of overpayments.

(f) CONTRACTOR shall only invoice for services that are covered under this

AGREEMENT, and shall ensure that no payments are made for services not covered, except when payments are specifically required to be made by the State in Title XIX of the Act, in 42 C.F.R., or when the state agency makes direct payments to

CONTRACTOR for graduate medical education costs approved under the State Plan.

(g) CONTRACTOR shall not bill enrollees for covered services any amount greater than would be owed if the entity provided the services directly (i.e., no balance billing by providers) per Section 1932(b)(6) of the Act; 42 C.F.R. Section 438.3(k); and 42 C.F.R.

Section 438.230(c)(1)-(2).

(h) Cost Sharing. This AGREEMENT requires that any cost sharing imposed on Medicaid enrollees is in accordance with Medicaid FFS requirements, including 42 C.F.R.

Sections 447.50-82. CONTRACTOR shall exempt from premiums any Indian who is eligible to receive or has received an item or service furnished by an Indian Health Care

Provider (IHCP) or through referral under contract health services. CONTRACTOR shall also exempt from all cost sharing any Indian who is currently receiving or has ever received an item or service furnished by an IHCP or through referral under contract health services.

(i) Insolvency. Medicaid enrollees shall not be held liable for CONTRACTOR’s debts in the event that CONTRACTOR becomes insolvent. Medicaid enrollees shall not be held liable for covered services provided to the enrollee for which the State does not pay the

CONTRACTOR, or for which the State or COUNTY does not pay CONTRACTOR under a contractual, referral, or other arrangement. Medicaid enrollees shall not be held liable for covered services furnished under a contract, referral, or other arrangement to the extent that those payments are in excess of the amount the enrollee would have owed if the CONTRACTOR covered the services directly.

2.5 Customary Charges Limitation

Notwithstanding any other provision in this AGREEMENT, COUNTY's total liability to

CONTRACTOR will not exceed CONTRACTOR's total Customary Charges for Psychiatric

Inpatient Hospital Services for each year in which this AGREEMENT is in effect. COUNTY may recoup any excess of total payments above such total customary charges for Psychiatric

Inpatient Hospital Services under Paragraph 2.4. As used in this Paragraph, Customary

Charges will have the meaning ascribed to that term in the Regulations.

2.6 Treatment Authorization and Claims Submission. As an express condition precedent to

COUNTY's payment obligations hereunder, CONTRACTOR will obtain approval of a

Treatment Authorization Request (TAR) for each Day of Service rendered to a Beneficiary.

The treatment authorization process will take place either prior to admission or after discharge, as set forth below:

(a) Preauthorization for Planned Admission. CONTRACTOR shall obtain preauthorization up to seven (7) days in advance for admission of a Beneficiary for Acute Psychiatric

Inpatient Hospital Services by submitting to COUNTY's Point of Authorization a TAR and such related documentation as may be specified by COUNTY in accordance with the applicable Regulations. When deemed necessary by COUNTY, COUNTY review of a TAR may include a psychiatric evaluation examination of the Beneficiary conducted at the time and place specified by COUNTY. If required, COUNTY will notify the attending physician and Beneficiary of the examination. If the medical necessity criteria set forth in the Regulations are met, COUNTY will approve the TAR and give preauthorization for payment for a specified number of Days of Service, not to exceed one (1) calendar month. COUNTY shall notify CONTRACTOR of its approval or disapproval of a TAR in writing within fourteen (14) calendar days of COUNTY's actual receipt of such TAR. Approval is effective, if granted, up to seven (7) calendar days in advance of the provision of services. All adverse decisions of COUNTY will be reviewed and approved by a COUNTY authorized physician. CONTRACTOR may appeal an adverse decision through the provider appeal process set forth in the

Regulations. If the TAR is denied prior to hospitalization, COUNTY will notify the

Beneficiary within ten (10) calendar days.

(b) Authorization for Payment for Emergency Admission. Payment authorization for emergency admissions will be exempt from preauthorization set forth in Paragraph

2.6(a) above, but will be subject to the provisions set forth in this Paragraph 2.6(b).

CONTRACTOR shall notify the COUNTY's Point of Authorization within twenty-four

(24) hours of the time of the admission or by the end of the next business day from the date of presentation for emergency services, of the Beneficiary to the Facility. A TAR for emergency admission and such related documentation as may be specified by the

COUNTY shall be submitted by the CONTRACTOR to the Point of Authorization after discharge of the Beneficiary, but no later than fourteen (14) calendar days following discharge. COUNTY will authorize payment for the emergency services received pursuant to the emergency admission if the clinical record documents that:

(1) The medical necessity criteria set forth in the Regulations are met.

(2) The criteria for an emergency psychiatric condition set forth in the Regulations were met at the time of admission.

(3) The COUNTY was notified within twenty-four (24) hours or the next business day from the presentation for emergency services. If notice exceeds ten (10) calendar days, COUNTY may deny payment to CONTRACTOR.

(4) The TAR and related documentation were received no later than fourteen (14) calendar days following discharge.

(5) All adverse decisions of COUNTY will be reviewed and approved by a

COUNTY authorized physician. CONTRACTOR may appeal an adverse decision through the provider appeal process set forth in the Regulations.

(c) Authorization for Payment for Continued Stay Services. To the extent permitted by federal and state law, TARS for Continued Stay services will be submitted only after discharge of the Beneficiary, but no later than fourteen (14) calendar days after discharge of the Beneficiary from the Facility; except that, notwithstanding the foregoing, CONTRACTOR will submit a TAR within fourteen (14) days of the completion of ninety-nine (99) calendar days of continuous services to a Beneficiary.

Payment authorization will be obtained through submission of a TAR and such related documentation as may be specified by the COUNTY to COUNTY's Point of

Authorization. If the medical necessity criteria set forth in the Regulations are met, the

TAR will be approved. COUNTY will notify CONTRACTOR of its decision no later than fourteen (14) calendar days after the COUNTY's actual receipt of the TAR.

COUNTY will provide a copy of the authorized or denied TAR to CONTRACTOR.

All adverse decisions will be reviewed and approved by a COUNTY authorized physician. CONTRACTOR may appeal an adverse decision through the appeal process set forth in the Regulations.

(d) Timeliness. A TAR may be denied by COUNTY if it is not submitted in accordance with the timing requirements contained in this Paragraph 2.6, unless CONTRACTOR was prevented from submitting a timely TAR due to the circumstances specified in the

Regulations.

(e) Claims Submission. Claims for payment for services rendered pursuant to this

Agreement will be submitted by the CONTRACTOR to the Fiscal Intermediary in accordance with the requirements set forth in Sections 51008 and 51008.5 of Title 22 of the California Code of Regulations. If the TAR is approved by COUNTY as provided in this Section, COUNTY will submit a copy of such approval to the fiscal intermediary. The fiscal intermediary will make the payments required hereunder to

CONTRACTOR on behalf of COUNTY.

2.7 Authorization for Administrative Days

Payment for Administrative Days hereunder is expressly conditioned upon

CONTRACTOR's compliance with the following provisions in addition to the provisions of Section 2.6 above and the definition of “Administrative Day” included in Appendix A:

(a) For patients requiring care in an Institution for Mental Diseases (IMD) or at the

State Hospital, approval must be granted from the COUNTY’s Behavioral Health

Services Director or her designee. This approval must then be reflected in the medical record documentation. The medical record must reflect that the patient was admitted to the first available IMD or State Hospital bed.

(b) For patients requiring care in the crisis residential system, approval must be granted by COUNTY or a program designated by COUNTY as appropriate. The medical record documentation must reflect that approval has been granted. The medical record must reflect that the patient was admitted to the first available crisis residential bed.

(c) For patients who are to be placed in a skilled nursing facility, the medical record must reflect that at least five appropriate facilities within a sixty (60) mile geographic radius per week are contacted for admission request. The medical record must reflect that the patient was admitted to the first available appropriate bed.

2.8 Authorization for Patients Awaiting Placement. Payment for Patients Awaiting Placement hereunder is expressly conditioned upon CONTRACTOR's compliance with the following provisions in addition to the provisions of Paragraph 2.6 above and the definition of “Patients

Awaiting Placement” is included in Appendix A.:

(a) For patients requiring care in an Institute for Mental Disease (IMD), Mental Health

Rehabilitation Center (MHRC), Supplemental Licensed Board and Care, or at the State

Hospital, approval must be granted from the COUNTY’s Mental Health Director or her designee. This approval must be reflected in the medical record documentation.

Further, the medical record must reflect that at least five appropriate facilities per week are contacted for admission request and indicate the bed availability at the facility. The medical record must reflect that the patient was admitted to the first available IMD, MHRC, Licensed Board and Care, or State Hospital bed. Patients in this category still require close monitoring in a locked PSYCHIATRIC INPATIENT HOSPITAL setting.

(b) For patients requiring care in the crisis residential system, approval must be granted by the COUNTY’s Mental Health Director or her designee, which may be, but is not limited to, Momentum for Mental Health, Community Solutions, or any other program designated by COUNTY. The medical record documentation must reflect that approval has been granted. Further, the medical record must reflect that at least five appropriate facilities per week are contacted for admission request and indicate the bed availability at the crisis residential program. The medical record must reflect that the patient was admitted to the first available crisis residential bed. Patients in this category continue to require close monitoring in a locked PSYCHIATRIC INPATIENT HOSPITAL setting.

(c) For patients requiring care in the Augmented Board and Care, approval must be granted by the COUNTY’s Mental Health Director or her designee. The medical record documentation must reflect that approval has been granted. Further, the medical record must reflect that at least five appropriate facilities per week are contacted for admission request and indicate the bed availability at the crisis residential program. The medical record must reflect that the patient was admitted to the first available crisis residential bed. Patients in this category still require close monitoring in a locked PSYCHIATRIC

INPATIENT HOSPITAL setting.

(d) For patients who are to be placed in a skilled nursing facility, the medical record must reflect that at least five appropriate facilities within a 60-mile geographic radius per week are contacted for admission request. The medical record must reflect that the patient was admitted to the first available appropriate bed. Patients in this category still require close monitoring in a locked PSYCHIATRIC INPATIENT HOSPITAL setting.

(e) The requirement to contact five appropriate facilities per week may be waived by the

COUNTY’s Mental Health Director or designee, and in no case will the number of facilities contacted be less than one per week.

2.9 Certification Hearing Fee

CONTRACTOR will reimburse COUNTY for fees related to State mandated Certification

Review, Riese and Voluntariness Hearings (CRH) for Psychiatric Inpatient Hospital patients. CRH fee is set by COUNTY Board of Supervisors. CRH are held pursuant to

Article 5256 of the California Welfare and Institutions Code (WIC), when a patient is detained beyond 72 hours under WIC 5150 for Certification for Intensive Treatment

2.10 State and Federal Funding Approval

The parties acknowledge and agree that this AGREEMENT is contingent on the availability of

Federal, State and County funds for the services described in this AGREEMENT including all applicable Exhibits.

2.11 Contractor Appeal Process

CONTRACTOR may file an appeal concerning the processing or payment of its claims hereunder for Psychiatric Inpatient Hospital Services directly to the fiscal Intermediary in accordance with the procedures set forth in the Regulations.

ARTICLE 3

RECORDS AND AUDIT PROVISIONS

3.1 On-site Reviews

(a) COUNTY, the State, the Office of the Inspector General (OIG), the Comptroller

General, and their designees will conduct periodic audits or reviews, including on-site audits or reviews, of performance under this AGREEMENT. These audits or reviews may evaluate the following:

(1) Level and quality of care, and the necessity and appropriateness of the services provided.

(2) Internal procedures for assuring efficiency, economy and quality of care.

(3) Compliance with COUNTY Client Grievance Procedures.

(4) Financial records when determined necessary to protect public funds.

(a) CONTRACTOR will make adequate office space available for the review team or auditors to meet and confer. Such space must be capable of being locked and secured to protect the work of the review team or auditors during the period of their investigation.

(b) On-site reviews and audits will occur during normal working hours with at least 72-hour notice, except that unannounced on-site reviews and requests for information may be made in those exceptional situations where arrangement of an appointment beforehand is clearly not possible or clearly inappropriate due to the nature of the intended visit.

3.2 Records to be Kept; Audit or Review: Availability, Period of Retention

CONTRACTOR covenants and agrees that:

(a) It will maintain books, records, documents, and other evidence, accounting procedures, and practices sufficient to reflect properly all direct and indirect costs of whatever nature incurred in the performance of this AGREEMENT.

(b) The above information will be maintained in accordance with Medicare and Medi-Cal principles of reimbursement and generally accepted accounting principles, and will be consistent with the requirements of the Office of Statewide Health Planning and

Development.

(c) CONTRACTOR will also maintain medical records required by Sections 70747 through

70751 of Title 22 of the California Code of Regulations, and other records related to a

Beneficiary to whom the service was rendered, the date of the service, the medical necessity of the service and the quality of the care provided. All such records will be maintained in accordance with Section 51476 of Title 22 of the California Code of

Regulations. Notwithstanding the foregoing, CONTRACTOR will maintain

Beneficiary medical and/or clinical records for a period of ten (10) years, except that the records of persons who are under the age of 18 at the time of treatment will be retained until either: (a) one year beyond the person's 18th birthday or (b) for a period of ten (10) years from the date of discharge, whichever period is later.

(d) The Facility and the information specified in this Paragraph will be subject at all reasonable times to inspection, audits and reproduction by any duly authorized agents of the COUNTY, State and Federal governments. CONTRACTOR agrees to allow the

COUNTY, State, and federal agencies including the Director, and/or any designated auditor of COUNTY, the State of California, including but not limited to officials from the State Department of Mental Health or the State Department of Health Services, any designated official of the Department of Health and Human Services, the Comptroller

General of the United States, or the fiscal intermediary, the right to inspect or otherwise evaluate the cost, quality, appropriateness, and timeliness of services performed and to audit and inspect any books and records of CONTRACTOR which pertain to services performed and/or determinations of the amounts payable under this AGREEMENT.

Copies of records will be made available upon COUNTY’s requests for copies of

CONTRACTOR’s records.

(e) CONTRACTOR will preserve and make available its records relating to payments made under this AGREEMENT for a period of ten (10) years from the close of

CONTRACTOR's fiscal year, or for such longer period, required by subparagraphs

(1) and (2) below.

(1) If this AGREEMENT is terminated, the records relating to the performance of

CONTRACTOR's obligations hereunder will be maintained by CONTRACTOR and made available for a period of ten (10) years from the date of the last payment made under the AGREEMENT; or

(2) If any litigation, claim, negotiation, audit or other action involving the records has been started before the expiration of the ten (10) year period, the related records will be retained until expiration of the ten (10) year period following the completion and resolution of all issues arising there from; whichever is later.

(f) CONTRACTOR will provide to each Beneficiary for completion a patient satisfaction survey form or perform a phone survey. Utilization of a research firm to perform this function is acceptable.