Exhibit_B_-_Budget_Detail_and_Paymt_Prov.pdf

California Department of Corrections and Rehabilitation (CDCR)/ Proposal Number: SD23-00097 California Correctional Health Care Services (CCHCS) Exhibit B Budget Detail and Payment Provisions

Rev. 9/19/2024 Page 1 of 4

ON-SITE DIALYSIS SERVICES

ARTICLE I

BUDGET DETAIL AND PAYMENT PROVISIONS

1. Claims and Payment

For services satisfactorily rendered, and upon receipt and approval of Contractor’s claims, California Department of Corrections and Rehabilitation/California Correctional Health Care Services (CDCR/CCHCS) agrees to compensate Contractor for completed services in accordance with the rates specified in Exhibit B-1 Rate Sheet, which is included as part of this Agreement. Except for emergency care, CDCR/CCHCS shall not compensate Contractor for services which did not receive prior authorization in accordance with Exhibit A Scope of Work, and/or exceed the services as defined in California Code of Regulations (CCR), Title 15, Section 3999.98 and 3999.200.

a. Services shall be completed as set forth in Exhibit A Scope of Work and in accordance with prior authorization provisions, and all other terms and conditions of this Agreement.

b. Claims shall be reimbursed in accordance with Exhibit B-1 Rate Sheet and with the following terms:

no CDCR/CCHCS employee may independently negotiate or implement a rate increase on behalf of CDCR/CCHCS. Rate increases must be formalized by Direct Care Contracts Section (DCCS) through a formal amendment. Any claim that is sent to CDCR/CCHCS with reimbursement rates above the specified rates by CDCR/CCHCS in writing within the contract shall be invalid. Payment of an erroneous claim does not constitute acceptance of the erroneous pricing and CDCR/CCHCS may seek reimbursement of the overpayment or may withhold such overpayment from future claims.

c. CDCR/CCHCS will not accept requests for early payment, down payment or partial payment.

2. Budget Contingency Clause

a. It is mutually agreed that if the California State Budget Act for the current fiscal year and/or any subsequent fiscal years covered under this Agreement does not appropriate sufficient funds for the program, this Agreement shall be of no further force and effect. In this event, the state shall have no liability to pay any funds whatsoever to Contractor, or to furnish any other considerations under this Agreement, and Contractor shall not be obligated to perform any provisions of this Agreement.

b. If funding for the purposes of this program is reduced or deleted for any fiscal year by the California State Budget Act, the state shall have the option to either cancel this Agreement with no liability occurring to the state, or offer an Agreement amendment to Contractor to reflect the reduced amount.

3. Prompt Payment Clause

Payment will be made in accordance with, and within the time specified in, California Government Code (GC) Section 927 et seq. Payment to a small business or microbusiness shall be made in accordance with, and within the time specified in, GC Section 927 et seq.

CDCR/CCHCS Proposal Number: SD23-00097 Budget Detail and Payment Provisions Exhibit B

Rev. 9/19/2024 Page 2 of 4

ARTICLE II

SPECIAL BUDGET DETAIL AND PAYMENT PROVISIONS

1. Submission of Claims

a. In order to ensure prompt and accurate payment, all claims shall be submitted according to the applicable directions listed below. It is the responsibility of Contractor to ensure that claims are sent to the correct address as set forth below according to service type. Claims sent to the incorrect address will be deemed not submitted, will not be processed for payment, and will not be subject to late payment penalties per GC Sections 927.2, subdivision (j) and 927.4.

b. All claims must be completed thoroughly, with all applicable fields completed. Claims that are submitted to the appropriate location, but have been altered, are inaccurate, or do not provide all necessary information, will not be accepted, and will be denied and returned to Contractor for correction.

c. Any changes to this provision relating to the claim submittal process, including but not limited to an address, form, or process change, shall be an administrative change managed through the appropriate designated CDCR/CCHCS office and shall not require an Agreement amendment.

d. Claims submitted shall include the information listed in section 2(f) and must be legible in order to be considered complete and acceptable for processing or the claim will be returned and disputed back to Contractor. Disputed/returned claims shall not be subject to late payment penalties, as set forth in GC Section 927.4.

2. Submission of Claims for Services/Procedures

a. Information concerning claims adjudicated for CDCR/CCHCS by CorrectCare Integrated Health (CCIH), CDCR/CCHCS’ Third Party Administrator may be accessed through the CCIH Web Portal.

Instructions for registration and use of the web portal, can be obtained by calling the CDCR/CCHCS Healthcare Invoicing Section (HIS) Help Desk at (916) 691-0699 or at:

https://tpa.correctcare.com/pp_reg/portal/

b. Pursuant to the California Prompt Payment Act, GC Section 927 et seq., undisputed claims shall be paid within 45 days of the date of receipt. If you do not have access to the CCIH Web Portal, contact the HIS Help Desk at (916) 691-0699 or via electronic mail (email) at m_HISProgramSupport@cdcr.ca.gov to verify receipt of claims.

c. CDCR/CCHCS shall render payment in accordance with and within the time specified in GC Section 927 et seq. CDCR/CCHCS reserves the right to deny Contractor’s claim if Contractor fails to submit it in the appropriate format or within the appropriate time frame specified in this section. CDCR/CCHCS will provide an explanation along with the claim denial and the basis for claim rejection. Contractor will have the right to appeal or otherwise resubmit the claim with the reasonably required documentation.

d. Claims submitted for payment must be typewritten, legible, accurate, and submitted within 12 months and/or one year after the provision of services. Claims submitted after 12 months and/or one year may not receive payment for these claims. Claims older than 12 months and/or one year shall be submitted in accordance with Exhibit D, Special Terms and Conditions & Additional Provisions, Section 2, Dispute Resolution Process, (b)(3) First Level Appeal.

https://tpa.correctcare.com/pp_reg/portal/ mailto:m_HISProgramSupport@cdcr.ca.gov

Budget Detail and Payment Provisions Exhibit B

Rev. 9/19/2024 Page 3 of 4

e. Claims submitted for payment shall be on a Center for Medicare & Medicaid Services (CMS) CMS- 1500 form or its successor(s) (if applicable) and shall itemize each service provided.

f. Claims submitted for payment shall include all applicable information listed below:

1. Patient’s CDCR number

2. Name of patient

3. Patient date of birth

4. Gender of patient

5. Patient housing institution acronym, city, state, and zip code

6. All required diagnosis codes

7. Date(s) of service

8. Place of service

9. All required Current Procedure Terminology (CPT)/Healthcare Common Procedure Coding

System (HCPCS) codes

10. Any required CMS codes, if applicable

11. Service units

12. Billed charges for services rendered (including total billed charges)

13. Contractor or provider’s National Provider Identifier (NPI) number

14. Contractor Federal Employer Identification Number (FEIN)/Federal Tax ID

15. Patient account number (as assigned by the billing entity)

16. First and last name of Contractor or provider performing services (In the event that Contractor or provider is a medical group, list the group name. The NPI number should reflect this listing.)

17. Service facility location information

18. Billing provider information

19. Any other medical information or documentation from external sources reasonably required to verify and substantiate the provision of services and the charges for such services.

g. Claims submitted for on-site services/procedures shall be submitted to the Third Party Administrator at the following address:

Correct Care Integrated Health PO Box 349026 Sacramento, CA 95834-9026

3. Rejection of Contractor’s Claim

CDCR/CCHCS reserves the right to reject a Contractor’s claim if Contractor fails to submit the claim in the appropriate format or within the appropriate time frame specified within this Agreement. Disputed claims will be returned to Contractor without payment and will include an explanation of the claim dispute.

Contractor will have the right to appeal or otherwise resubmit the claim with the pertinent documentation to the address above. Disputed/returned claims shall not be subject to late payment penalties, as set forth in GC Section 927.4.

4. Claim Audits and Refunds

CDCR/CCHCS has the right to review claims retrospectively to ensure claims were processed correctly and per the contract terms. Should CDCR/CCHCS determine that claims resulted in an overpayment;

CDCR/CCHCS shall request a refund in the incorrect dollar amounts. Contractor shall refund any monies

Budget Detail and Payment Provisions Exhibit B

Rev. 9/19/2024 Page 4 of 4 found from these retrospective audits. Contractor shall refer to Exhibit D Section 63 for specific information regarding overpayments.

5. Claim Payment Inquiry

Should Contractor have questions or concerns regarding the processing and/or payment of claims, the parties shall make a first attempt in good faith to resolve the question or concern through informal discussion(s). The parties agree that the HIS should be used as a resource in solving potential patient health care invoice disputes. Contractor shall refer to Exhibit D Special Terms and Conditions & Additional Provisions, of this Agreement for detailed dispute information.

6. Healthcare Invoicing Section (HIS) Help Desk

Contractor shall contact the HIS Help Desk at (916) 691-0699 or via email at m_HISProgramSupport@cdcr.ca.gov with any questions regarding the health care service/procedure claims submittal or dispute process. If resolution to the patient claim cannot be resolved via the verbal inquiry process, Contractor shall refer to the formal health care claim appeal process outlined in Exhibit D Special Terms and Conditions & Additional Provisions of this Agreement.

mailto:m_HISProgramSupport@cdcr.ca.gov