Sample_Contract.pdf

2. The term of this Agreement is:

SAMPLE

California Department of Corrections and Rehabilitation (CDCR)/ Bid Number: SD24-00035 California Correctional Health Care Services (CCHCS) Exhibit A Scope of Work

Rev. 7/16/2025 Page 1 of 8

HEARING AID SERVICES AND DEVICES

1. Introduction/Services

a. This is a statewide Agreement in which the Contractor and/or Provider shall provide on-site Hearing Aid Services and Devices on an as-needed basis to patients referred for such health care services from California Department of Corrections and Rehabilitation/California Correctional Health Care Services (CDCR/CCHCS) Institutions.

b. For purposes of this Agreement, “Contractor” is the party hereby contracting with CDCR/CCHCS and who is presumed to be qualified to have an active role under this Agreement as a Provider of Hearing Aid Services and Devices.

c. For purposes of this Agreement, the term “Provider” shall refer to any Provider who renders hearing aid services and devices pursuant to this Agreement, as arranged through and/or associated with Contractor, as Contractor’s employee, independent contractor, and/or sub-contractor. “Provider” includes Contractor with respect to any instance or capacity, in which, Contractor is, or may be, acting as a Hearing Aid Services and Devices Provider.

d. Contractor and/or Provider must provide all labor, equipment, supplies, staff, transportation, licenses, permits, certificates, and every other item of expense necessary, or incurred in providing hearing aid services and devices, including any expense anticipated or incurred by Contractor and/or Provider associated with travel to and from an institution. This includes, but is not limited to lodging, food, or any other travel expenses, as well as any expenses associated with work-related training and shall be the sole obligation of the Contractor and/or Provider incurring the expense. CDCR/CCHCS has no obligation to pay or reimburse any such expense incurred by Contractor and/or Provider. Any lost/damaged equipment costs due to CDCR/CCHCS negligence will be negotiated with CCHCS Direct Care Contracts Section

(DCCS).

e. Services shall be provided at the direction of the institution Chief Executive Officer/Chief Medical Executive (CEO/CME) or designee. For purposes of this Agreement, CDCR/CCHCS designee must be a civil service employee. The institution CEO/CME or designee retains professional and administrative oversight for services provided. CDCR/CCHCS reserves the right to consult with an independent third-party in the oversight services. The responsibility of CDCR/CCHCS to provide hearing aid services and devices is limited to those services which are reasonable and medically necessary to protect life, prevent significant illness or disability, or alleviate severe pain that significantly disables the patient from reasonable independent function, and are supported by outcome data as being effective care.

f. Any service or treatment that is not medically necessary shall safely be deferred until the patient is released from custody. Any service considered under this Agreement is otherwise subject to the prior authorization requirement and all other requirements, processes, and limitations expressed herein, such as the request and scheduling process, and/or other limitations and requirements as imposed by law.

g. Contractor and/or Provider shall perform services pursuant to this Agreement, and in accordance with CDCR/CCHCS policies and procedures, and federal and state laws and regulations. Contractor and/or Provider shall, at all times, comply with standard safety

CDCR/CCHCS Bid Number: SD24-00035 Scope of Work Exhibit A

Rev. 7/16/2025 Page 2 of 8 precautions and maintain CDCR security measures and a safe work environment.

h. Contractor and/or Provider must possess and maintain throughout the term of this Agreement, valid and unconditional licensure and/or board certification with no pending accusations from the applicable boards by which they are licensed and/or certified to practice in the area of medical specialty.

i. Contractor bears the responsibility for the provision of hearing aid services and devices and performing any associated task in a manner consistent with the commonly accepted standard of care. Any and all services performed outside the scope of this Agreement will be at the sole risk and expense of the Contractor and/or Provider. CDCR/CCHCS does not assume, agree to, or otherwise accept a duty to defend or indemnify a provider against any civil or criminal action arising out of or in association with this Agreement.

j. Contractor and/or Provider agree that any excluded health care service or treatment needed for pre-existing conditions shall be provided only in the event that the condition has become exacerbated in such a manner that it poses a significant threat to the patient’s current health and if not treated would result in morbidity and/or mortality. Contractor and/or Provider acknowledge the health care service or treatment must be recognized as medically necessary.

k. Contractor and/or Provider shall ensure that all ordered health care services shall be scheduled consistent with the severity of the medical need. Once scheduled, services shall be delivered at the time scheduled, unless unavoidable circumstances occur.

2. Contractor and/or Provider Responsibilities

a. Contractor and/or Provider must provide services to all institutions awarded on Exhibit B-1 – Bid Rate Sheet, and meet the requirements specified in Exhibit A-1 – Service Specifications.

Contractor and/or Provider must provide the State with proof of any required training, licenses, permits, certifications, and any other required documents as stated in Exhibit A-1 – Service Specifications and as required by law. Services will be performed only by Contractor and/or Provider who meet the requirements outlined in this Agreement.

b. Standards of Obligation

(1) Contractors and/or Provider must acknowledge and adhere to the CDCR/CCHCS medical staff bylaws, rules, regulations, policies, and procedures as directed by the institution CEO/CME or designee and comply with universal infection control precautions.

(2) Contractor and/or Provider recognizes that CDCR/CCHCS acts in a fiduciary capacity to the State of California (the State) and that this fiduciary duty extends to the provision and management of medical health care services, mental health care services, and dental services for the patient of the State of California. To assist CDCR/CCHCS in its exercise of this duty, Contractor and/or Provider shall provide high quality services, consistent with the terms and conditions under this Agreement and consistent with established and commonly accepted standards and principles of medical practice. Nothing in this Agreement shall supersede the common law rules for the interpretation of established and commonly accepted standards and principles of medical practice.

c. Reports

CDCR/CCHCS reserves the right to request that Contractor and/or Provider submit electronic

Rev. 7/16/2025 Page 3 of 8 reports or information related to this Agreement, as requested. Report submission details, including frequency of requested reports, shall be determined by CDCR/CCHCS, upon execution of the Agreement, and in consultation with the Contractor and/or Provider.

CDCR/CCHCS may require reports to include additional information pertaining to a Provider, including, but not limited to, name, social security number, date of birth, etc. Non-compliance may result in termination of the Agreement. The reports shall be submitted by a mutually agreeable timeframe but no later than forty-five (45) calendar days of request.

The reports shall be submitted in a secure HIPAA compliant electronic format (Microsoft Excel 2000 or newer version) and sent via electronic mail (email) to m_ContractSupport@cdcr.ca.gov. In the event that email is not available the reports can be sent via U.S. Mail to the following address:

California Correctional Health Care Services Attn: Direct Care Contracts Section P.O. Box 588500 Elk Grove, CA 95758

d. Contract Managers

The Clinical Contract Managers during the term of this Agreement will be:

State Agency Contractor Entity Name: California Correctional Health

Care Services

TBD

Division/Unit: Medical Services Name: Grace Song, M.D.

Address: 10750 Fourth St, Suite 150

Rancho Cucamonga, CA 91730

Phone: (916) 215-6919 Email Grace.Song@cdcr.ca.gov

The Administrative Managers during the term of this contract will be:

State Agency Contractor Entity Name: California Correctional Health

Care Services

TBD

Division/Unit: Direct Care Contracts Section / Contract Support Team

Name: Michelle Kwong Address: 8280 Longleaf Drive, Building D

Phone: (916) 691-2358 Email m_ContractSupport@cdcr.ca.gov

The parties may change their Contract or Administrative Managers upon providing 10 days written notice to the other party. Said changes shall not require an amendment to this Agreement.

mailto:m_ContractSupport@cdcr.ca.gov mailto:Grace.Song@cdcr.ca.gov

Rev. 7/16/2025 Page 4 of 8

e. Prior Authorization for Treatment

Excluding emergency care services, prior authorization must be obtained in writing from the institution CEO/CME or designee via CDCR/CCHCS Request for Service (RFS), in accordance with CCHCS’ Utilization Management (UM) Plan. Contractor and/or Provider shall complete and return all forms required by CDCR/CCHCS regarding treatment of patients. Authorization must be documented in the patient’s Electronic Health Record in all cases of essential services as well as any consultations by specialty physicians or diagnostic procedures not specifically stated in a CDCR/CCHCS prior authorization form. Except for emergency care, CDCR/CCHCS shall not render payment for services that do not have prior authorization; and/or if CDCR/CCHCS determined services were not medically necessary or if services were inappropriately delivered.

f. Experimental and Investigational Drugs and Procedures

Contractor and/or Provider shall not perform or administer to any patient any experimental or investigational treatment, therapy, procedure or drug. Any such treatment, unless it is related to specific California legislative provisions, is prohibited under Penal Code, Section 3502, and thus requires prior authorization from the appropriate institution CEO/CME or designee.

Contractor and/or Provider shall perform or administer only those health care services which are recognized as being in accordance with generally accepted professional medical standards, or as being safe and effective for use in the treatment of an illness, injury or condition at issue.

g. Exclusions and Limitations

(1) Contractor and/or Provider agree that no health care service or treatment shall be provided for those conditions specifically listed in the California Code of Regulations (CCR), Title 15, Division 3, Chapter 2, Subchapter 2, Article 1, Section 3999.200. Contractor and/or Provider may request approval for individual case exceptions for excluded or limited health care service or treatment by seeking prior approval of the institution CEO/CME or designee.

(2) Contractor and/or Provider shall be able to perform the tasks associated with providing the above health care services under the scope of their license and assume full responsibility for the provision of these services.

h. Required Notices

Except as otherwise provided in this Agreement, any notice required hereunder shall be deemed to be sufficient if sent via email or U.S Mail to CDCR/CCHCS contact information located in Provision 14. If mail via the United States Postal Service is used to give any notice required in this Agreement, notice shall be deemed as given on the day after it is deposited in the United States mail with First Class postage prepaid and addressed to CDCR/CCHCS. Only actual written notice will suffice for the purpose of meeting any notice requirement in this Agreement.

i. Fit Testing

(1) Contractor shall ensure that Provider is in compliance with Title 8 CCR 5144 standards, including providing medical evaluation to determine the provider's ability to use a respirator before the provider is fit tested or required to use the respirator in the workplace. Contractor

Rev. 7/16/2025 Page 5 of 8 shall identify a physician or other licensed health care professional (PLHCP) to perform medical evaluations using a medical questionnaire or an initial medical examination that obtains the same information as the medical questionnaire. Contractor shall provide additional medical evaluations if:

a) Provider reports medical signs or symptoms that are related to the ability to use a respirator;

b) A PLHCP, supervisor, or the respiratory protection program administrator informs the provider that they need to be reevaluated;

c) Information from the respiratory protection program, including observations made during fit testing and program evaluation, indicates a need for provider reevaluation; or

d) Change occurs in workplace conditions (e.g., physical work effort, protective clothing, temperature) that may result in a substantial increase in the physiological burden placed on a provider.

(2) Contractor shall ensure the provider is fit tested with the same make, model, style, and size of respirator that will be used. Provider must be fit tested on a NIOSH-certified N95 respirator annually, within twelve (12) months of the last fit test. Provider shall obtain an additional fit test whenever there is a change or if the contractor or the PLHCP makes visual observations of changes in the provider's physical condition that could affect respirator fit. Such conditions include, but are not limited to, facial scarring, dental changes, cosmetic surgery, or an obvious change in body weight. Fit testing records must include name of provider, date of testing and respirator(s) make, model, and size, if applicable. Fit testing records must be provided to the CDCR/CCHCS upon request.

(3) Contractor shall provide respiratory protection training to providers annually and more often if necessary.

3. Request for Services

a. Contractor and/or Provider agrees to provide on-site direct health care services as arranged with the institution CEO/CME or designee upon request, in accordance with each institution’s policies and procedures.

b. Contractor shall have a telephone number and email address, as well as a designated representative available by telephone during normal hours of clinic operation for the duration of the Agreement. Clinic hours may vary between the hours of 6:00 a.m. and 5:00 p.m. (PST), Monday through Friday. Telephone answering devices (i.e., message machines) and answering services are not permitted, and their use may be cause for termination of this Agreement. The initial contact will be by telephone; however, CDCR/CCHCS will follow-up with email.

c. The State reserves the right to award multiple Agreements for back-up purposes. Institutions will utilize the Rank 1 Contractor when services are needed. If the Rank 1 Contractor is unable to provide services, or if an urgent and emergent situation arises, CDCR/CCHCS may, at the discretion of the institution CEO/CME or designee, contact lower ranked Contractors in order

Rev. 7/16/2025 Page 6 of 8 of rank until the institution has met its needs. This process will be repeated based on the number of Agreements awarded and start over each time the institution needs to contact lower ranked Contractors to request services.

d. Contractor with multiple agreements for the same service and same institution and shall be obligated to provide services at the same rates in the primary contract until all the obligations under the primary contract are attained before the secondary or subsequent contract can be in effect. The only exception to this provision occurs when the rate(s) in a subsequent agreement is lower than those of the primary agreement; the State then has the sole right to determine which rate(s) will be applied.

e. Contractor acknowledges that the institution may request for on-site services to be provided at any time, including weekends and holidays.

4. Responding to a Request for Service

a. Contractor shall respond to institution request for services within the standard response time of two (2) hours, unless otherwise stated by CDCR/CCHCS. CDCR/CCHCS may extend the response time, at the discretion of the institution CEO/CME or designee, and dependent upon the urgency of the request for services. The response time shall be included on the request for service. CDCR/CCHCS reserves the right to accept a response from other Contractor(s) after the response time has elapsed.

b. Contractor and/or Provider shall respond to the institution’s request for documentation as part of the request for services, which may include, but not limited to, copies of any current and valid licenses, permits, and/or certifications, unless already on file. A response without the necessary or requested supporting documentation as described above may be deemed as non-responsive and the next ranked Contractor(s) will be contacted.

5. Scheduling

a. Contractor and/or Provider shall ensure that all ordered services have prior authorization in accordance with institution UM and are mutually agreed upon between the institution CEO/CME or designee and the Contractor.

b. At the time of scheduling, institutions shall provide the Contractor and/or Provider with an estimated period of time the institution anticipates the need for contracted services. This will be a good faith estimate based on the circumstances known to CDCR/CCHCS at the time of the request. It is not a guarantee of business and is subject to change depending on CDCR’s fluctuations in CDCR patient population. However, CDCR/CCHCS shall endeavor to provide five (5) business days’ notice prior to cancellation of clinics.

c. Contractor shall provide services to the institution at the time mutually agreed upon between the institution Contract Liaison or designee and Contractor.

6. Overtime Pay Rate Allowances

No overtime pay will be authorized under this Agreement.

7. Holiday Pay Rate Allowances

No holiday pay rate will be authorized under this Agreement.

Rev. 7/16/2025 Page 7 of 8

8. Telephonic Consultations

No telephonic consultations will be authorized under this Agreement.

9. Orientation and Training

At the discretion of each institution, Contractor and/or Provider agrees that prior to reporting to work at the institution; all providers shall complete orientation/training as specified below at the Contractor’s sole expense:

a. On-site Institution Orientation/Training

Contractor agrees that all providers shall attend on-site orientation and any other required training (i.e. annual block training and Learning Management System [LMS]) prior to reporting to work at the institution. Orientation/training is designed to assist providers to become familiar with the operations of the institution, its medical facilities, and Title 15 of the CCRs. To maintain continuity of services and ensure safety for all workers, Contractor shall make available to the institution only those providers who have completed the orientation.

b. Self-Certification Orientation Process

This process may be utilized in place of attending an on-site institution orientation based on institution approval. The parties agree that there will be no reimbursement for assigned providers who have been approved to utilize the Self-Certification Orientation Process.

(1) Contractor shall obtain a copy of the Health Care On-Site Contractor’s Orientation Handbook from institution and return the signed copy of the CCHCS Orientation Acknowledgement form once complete.

(2) Contractor shall be responsible for ensuring that all providers complete the orientation and sign the Self-Certification Acknowledgement.

(3) Contractor shall maintain the signed copies (new and renewed) of the CCHCS Orientation Acknowledgement and provide to CDCR/CCHCS upon request.

10. Inspections

Inspections may be carried out by the institution CEO/CME or designee, at various times during the Agreement term to check on the quality and quantity of work and determine acceptability of work performed before Agreement payment will be approved.

11. Failure to Perform

a. CDCR/CCHCS shall routinely evaluate the work performance of Contractor and/or Provider to determine if CDCR/CCHCS standards and departmental/institutional policies and procedures are being met. Contractor and/or Provider who fail to perform or who are physically or mentally incapable of performing the required duties as required by this Agreement shall not be permitted to perform service. The institution CEO/CME or designee shall state in writing the reasons Contractor and/or Provider did not meet the required policies or standards and submit a copy to Contractor and to the Contract Support Team at m_ContractSupport@cdcr.ca.gov.

Rev. 7/16/2025 Page 8 of 8

b. CDCR/CCHCS shall not pay Contractor and/or Provider for any services performed by Contractor and/or Provider which are deemed unacceptable in accordance with the required services anticipated by this Agreement.

c. Failure to provide services on three (3) or more occasions may result in termination of the Agreement or the institution not having to contact the first ranked Contractor prior to contacting the other Contractors for the duration of the Agreement term. DCCS Staff Services Manager III (SSMIII) or designee has the sole discretion in this decision.

12. Department of Corrections and Rehabilitation Contact Information

a. Billing/Payment Issues:

Goods/Durable Medical Equipment Sacramento Regional Accounting Office Attention: Accounts Payable “A” P.O. Box 187015 Sacramento, CA 95818-7015 Email address: APA.invoices@cdcr.ca.gov

b. Scope of Work/Performance Issues:

Refer to Exhibit G - List of Participating CDCR Institutions for addresses and telephone numbers. The institution contract representative can be contacted Monday through Friday from 8:00 a.m. to 4:00 p.m. The institution contract representative or designee shall pre-arrange all needed services to ensure continuity of care.

c. General Agreement Issues:

California Correctional Health Care Services Direct Care Contracts Section – Contract Support Team P.O. Box 588500 Elk Grove, CA 95758 Phone Number: (916) 691-0698 Email address: m_ContractSupport@cdcr.ca.gov

SAMPLE

mailto:APA.invoices@cdcr.ca.gov

California Department of Corrections and Rehabilitation (CDCR)/ Bid Number: SD24-00035 California Correctional Health Care Services (CCHCS) Exhibit A-1 Service Specifications

Rev. 7/16/2025 Page 1 of 5

1. Contractor and/or Provider Qualifications

Contractor and/or Provider rendering services to California Department of Corrections and Rehabilitation/California Correctional Health Care Services (CDCR/CCHCS) institutions under this Agreement must have the minimum experience outlined below:

a. Minimum of twelve (12) continuous months of experience within the last three (3) years performing services similar in scope to those defined herein, in a public or private setting.

Internship/Apprenticeship does not count towards the required experience.

b. Proficient in the English language and be able to communicate effectively, orally and in writing, with CDCR/CCHCS patients and staff.

Contractor and/or Provider who fail to meet the minimum qualifications shall not be permitted to render services. The institution Chief Executive Officer/Chief Medical Executive (CEO/CME) or designee shall state in writing the reason(s) Contractor and/or Provider does not meet minimum qualifications and submit it to CCHCS Contract Support Team at m_ContractSupport@cdcr.ca.gov.

After notification of failure to meet minimum qualifications has been provided, CDCR/CCHCS shall not pay Contractor and/or Provider for any additional services identified as not meeting the minimum qualifications.

2. Licenses, Permits, and Certification Requirements

Contractor and/or Provider must have the required licenses, permits, and/or certifications as stated below and as required by law prior to providing services as outlined in this Agreement. Contractor and/or Provider shall:

a. Possess and maintain throughout the term of this Agreement, a current and valid license issued by the State of California, Department of Consumer Affairs, and Hearing Aid Dispensers Board, in order to perform services in the State of California.

b. Possess and maintain throughout the term of this Agreement, current and valid Basic Life Support (BLS) certification(s) accredited by the American Heart Association or the American Red Cross. Advanced Cardiovascular Life Support (ACLS) certification(s) accredited by the American Heart Association or the American Red Cross will also be accepted in place of BLS certification(s).

c. Ensure all medical and professional staff, and subcontractors are duly licensed, permitted, and/or certified, and absent of restrictions on said licensure, certification, and/or registration, as required by the applicable boards and by the laws of the State.

d. Provide copies of any current licenses, permits, and/or certifications for all medical and professional staff, and subcontractors providing services under this Agreement, to the institution CEO/CME or designee, to be kept on file at the institution, throughout the term of the Agreement.

Contractor and/or Provider shall render current licenses, permits, and/or certifications to CCHCS/CDCR no less than thirty (30) calendar days prior to their expiration. If, during the course of this Agreement, any of the licenses and/or requirements are found to be revoked, Service Specifications Exhibit A-1

Rev. 7/16/2025 Page 2 of 5 suspended, inactive, or not in compliance, CDCR/CCHCS may withhold payment for services rendered during the expiration period and/or immediately terminate this Agreement.

e. Assume responsibility for verifying through the appropriate certification boards that no current or unresolved disciplinary actions have been taken by State authorities against Contractor or any Provider assigned to CDCR/CCHCS, and that all licenses are active and void of misconduct.

CDCR/CCHCS may verify the status of Contractor and/or Provider assigned at its discretion.

f. Contractor and/or Provider(s), regardless of vaccination or accommodation status, may be subjected to mandatory COVID-19 testing as required by CDCR/CCHCS. Contractor and/or Provider(s) shall follow further directions regarding the COVID-19 requirements released by

CDCR/CCHCS.

3. Contractor and/or Provider Responsibilities

At the request of the institution CEO/CME or designee, Contractor and/or Provider shall render services and devices as permitted within the scope of practice for hearing aid services and devices, in accordance with institution policies and procedures. Duties/responsibilities shall include, but are not limited to:

a. Adherence to CDCR/CCHCS and State laws, regulations, policies, and procedures regarding patient confidentiality, written and electronic medical record documentation, and the release of patient records.

b. Ensure hearing aid equipment brought on-site for the performance of the contracted duties meets all regulatory compliance, and calibrations, including any requirements for sterilization.

CDCR/CCHCS institutions reserve the right to request verification of equipment compliance prior to equipment being brought into the institution, and throughout the term of this Agreement as necessary. CDCR/CCHCS is not responsible for ensuring storage or compliance of the equipment. Equipment shall not be stored overnight at an institution.

c. Provide a minimum of twenty-four (24) hours written notice prior to bringing into the institution any hearing aid equipment that has not specifically been authorized by CDCR/CCHCS institution. Approval must be obtained by the institution prior to arrival.

d. Possess a minimum number of providers to provide services to all institutions awarded on Exhibit B-1 – Bid Rate Sheet, who meet the requirements specified in Exhibit A-1 – Service Specifications.

e. If Contractor and/or Provider is unable to perform due to illness, resignation and/or factors beyond Contractor’s control, Contractor shall submit qualifications of proposed provider to the institution for approval as soon as possible but no more than five (5) business days before the provider’s report date. The institution CEO/CME or designee, shall approve, in advance, proposed providers assigned to this Agreement. Failure to do so may be cause for termination of this Agreement. The institution shall be notified of any changes to Contractor’s list of providers at least five (5) business days before the provider’s report date.

f. If a provider is dismissed or declined at an institution, Contractor shall immediately provide notification of the dismissal to the CEO/CME or designee of all other institutions where said provider renders or plans to render services.

Rev. 7/16/2025 Page 3 of 5

g. Contractor and/or Provider shall ensure that all ordered health care services are medically necessary and shall be scheduled consistent with the severity of the medical need. Once scheduled, services shall be delivered at the time scheduled, unless unavoidable circumstances occur. Contractor and/or Provider shall be able to perform the tasks associated with providing health care services and assumes full responsibility for the provision of these services.

h. Contractor and/or Provider shall perform and interpret tests of auditory function, pure tone audiometry and speech tests. The CEO/CME or designee has sole discretion as to the acceptability of work rendered by the Contractor and/or Provider.

4. Testing/Services

a. Pure Tone Audiometry and Speech Tests

(1) Pure tone audiometry and Speech tests must be performed according to the current American National Standards Institute (ANSI) standards.

(2) Patients with sensorineural or mixed hearing loss with 35 to 89 dB hearing levels in the pure tone average (PTA) of 500, 1000, and 2000 Hz should be fitted for a Conventional Standard Hearing Aid.

(3) Patients with sensorineural or mixed hearing loss with 90 dB or greater hearing levels in the PTA of 500, 1000, and 2000 Hz should be fitted for a Conventional High-Power Hearing aid.

(4) Patients with sensorineural or mixed hearing loss with 90 dB or greater hearing levels in the PTA of 500, 1000, and 2000 Hz and speech discrimination of less than 40% in both ears who have already tried Conventional High-Power Hearing aids set to maximum gain and comfort for at least six (6) months, and aided speech discrimination continues of less than 40% in both ears, the patient should be recommended for cochlear implant evaluation.

b. Contractor and/or Provider shall perform Pure Tone Audiometry and Speech Tests on referred patients for the sole purposes of fitting and maintaining hearing aids or recommendation to refer the patient to the Ear, Nose, and Throat (ENT) physician when indicated.

c. Contractor and/or Provider shall provide an auditory function (Pure Tone Audiometry and

Speech Tests) and hearing assessment report during the initial hearing aid evaluation. The report shall contain current hearing complaints, past hearing history findings, the Pure Tone Audiometry and Speech Tests results summary, and recommendations for the patient’s hearing ability to function in the institution’s general population. Contractor and/or Provider shall document the report in the patient’s chart, including whether the patient achieves effective communication after the hearing aid fitting.

d. Conduct a follow-up examination with recipients of new hearing aids, according to the American

Speech Hearing Association Preferred Practice Patterns for Outcome Evaluation and Follow-up Measures, approximately thirty (30) to ninety (90) days after fitting the hearing aid and every twelve (12) months thereafter. Contractor and/or Provider shall conduct follow-up examinations to ensure the patient is benefiting from the device, patient is able to utilize the device, assist with troubleshooting, and determine if a higher-power device is needed. The Contractor and/or Provider shall document the examinations and findings in the patient’s chart.

Rev. 7/16/2025 Page 4 of 5

5. Goods/Equipment

a. Contractor and/or Provider shall provide all equipment and supplies necessary to perform an audiometric hearing evaluation on referred patients. Equipment and supplies shall include, but are not limited to: microphones, accessory cords, pre-amplifications, ear bud accessories, charger(s), and batteries (rechargeable).

b. Contractor and/or Provider shall take impressions for the manufacturing of hearing aid devices and ensure the fitting of devices. Contractor and/or Provider shall fit and supply all ear domes, ear molds, and hearing aid instruments, and shall warrant same for a minimum of one (1) year from date of delivery (excluding batteries).

(1) Hearing aid devices shall be registered with the United States Food and Drug

Administration. Hearing aids shall be digitally programmable based on manufacturer specifications and requirements. This shall include, but may not be limited to, programmable functions allowing the adjustment of the frequency response, gain, output, and other characteristics. Hearing aids shall not utilize Bluetooth or similar technology. The following specifications shall be included:

(a) Five (5) or more channels;

(b) Three (3) or more programs;

(c) Adaptive directional microphone technology, unless not technologically feasible due to the size of the instrument;

(d) Adaptive signal processing;

(e) Noise reduction strategies for steady state and transient noise;

(f) Programs the patient can adjust;

(g) Active feedback suppression;

(h) Harmonic distortion at 500 Hz, 800 Hz, and 1600 Hz according to the procedures specified in ANSI/ASA S3.22-2014 shall be less than 8%;

(i) Equivalent input noise level measured according to the procedures specified in

ANSI/ASA S3.22-2014 shall not exceed 29 dB (for power instruments, the equivalent input noise level measured according to these procedures shall not exceed 32 dB); and

(j) Telecoil capability, except when not commercially available or not technically feasible.

(2) Fit all hearing aids according to the American Speech Hearing Association’s Preferred Practice Patterns for Hearing Aid Selection and Fitting. Ear domes and ear tips for Behind the Ear (BTE) instruments: Ear tips, domes, and sleeves shall be available in varying sizes and include both occluded and open non-occluding designs. Ear domes must include both standard and half shell styles and include various venting options.

(3) Custom ear molds shall be provided if clinically indicated.

c. Contractor shall provide a range of models appropriate for mild, moderate, severe, and profound hearing losses, and that there are models appropriate for each hearing loss and contain a tinnitus sound generator, if necessary. Contractor shall provide at least one “power” hearing aid model, defined as “a hearing aid which has a matrix at or above a maximum power output of 125 dB SPL and average gain of 60 dB or above”.

d. Contractor and/or Provider shall be responsible for minor repair services of hearing aids supplied by Provider to the patients. Minor repair work shall be performed at the institution.

Repairs completed during clinics shall not be billed separately. Major repair work performed off-

Rev. 7/16/2025 Page 5 of 5 site shall be returned by Provider within ten (10) days of removing the equipment from the institution. If necessary, Provider may be required, at no additional cost to the state, to provide a temporary hearing aid to patients whose hearing aids must be repaired off-site. Major repair work shall be warranted for a period of one (1) year from the date of repair; written documentation of all such repairs, including detailed information regarding the vendor used, the date of the repair, and the specific repairs performed.

e. Contractor and/or Provider shall issue patients that require hearing aids no more than one (1) hearing aid per ear. Additional hearing aids in a one (1) year time span require the institution CEO/CME or designee, approval.

f. Contractor and/or Provider shall ensure consultation and progress reports are completed as required in the patient’s chart and/or outpatient health report. Patients requiring more comprehensive audiology testing than what the portable equipment used in the clinic can provide shall be referred to the institution CEO/CME or designee, who will authorize or determine the need for a more specialized exam and/or complete evaluation; and maintain continuity of care until treatment is complete.

Criteria for Referral to ENT physician in situations including, but not limited to:

(1) Congenital atresia of the ear canal in both ears.

(2) Any conductive hearing loss caused by the outer ear or middle ear that failed treatment or cannot be managed by the primary care provider.

(3) History of sudden onset of sensorineural hearing loss or fluctuating sensorineural hearing loss in one or both ears.

(4) Suspected malingering or symptom magnification.

(5) Significant air-bone gap.

6. ACKNOWLEDGEMENT OF DUTIES

a. Contractor As Contractor, I hereby certify that I have read the above Hearing Aid Services and Devices Service Specifications including Contractor and/or Provider qualifications; Licenses, Permits and Certification Requirements; and Contractor and/or Provider responsibilities and that I understand the duties/responsibility required to successfully perform the services stated herein.

b. Additional Provider hired by the Contractor As the Provider hired by Contractor, I hereby certify, that I have discussed the above Hearing Aid Services and Devices service specifications including Contractor and/or Provider qualifications;

licenses, permits and certification requirements; and Contractor and/or Provider responsibilities. I understand the duties/responsibilities required to successfully provide the services stated herein.

Print Name of Contractor’s Representative Signature Date

Print Name of Provider Signature Date

California Department of Corrections and Rehabilitation (CDCR)/ Bid Number: SD24-00035 California Correctional Health Care Services (CCHCS) Exhibit B Budget Detail and Payment Provisions

Rev. 7/16/2025 Page 1 of 7

HEARING AID SERVICES AND DEVICES

ARTICLE I

BUDGET DETAIL AND PAYMENT PROVISIONS

1. Invoices/Claims and Payment

a. For services satisfactorily rendered, and upon receipt and approval of Contractor’s invoices/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 – Bid 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 Exhibit A-1 – Service Specifications, and/or exceed the services as defined in California Code of Regulations (CCR), Title 15, Section 3999.98 and 3999.200.

b. Services shall be completed as set forth in Exhibit A – Scope of Work, and/or Exhibit A-1 – Service Specifications, and in accordance with prior authorization provisions, and all other terms and conditions of this Agreement.

c. Invoices/claims shall be reimbursed in accordance with Exhibit B-1 – Bid 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 invoice/claim that is sent to CDCR/CCHCS with reimbursement rates above that specified by CDCR/CCHCS in writing within the contract shall be invalid. Payment of an erroneous invoice/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 invoices/claims.

d. 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.

Budget Detail and Payment Provisions Exhibit B

Rev. 7/16/2025 Page 2 of 7

4. Subcontractors

For all Agreements, with the exception of Interagency Agreements and other governmental entities/auxiliaries that are exempt from bidding, nothing contained in this Agreement, or otherwise, shall create any contractual relationship between the State and any subcontractors, and no subcontract shall relieve Contractor of Contractor’s responsibilities and obligations hereunder. Contractor agrees to be as fully responsible to the State for the acts and omissions of its subcontractors and of persons either directly or indirectly employed by any of them, as it is for the acts and omissions of persons directly employed by Contractor. Contractor’s obligation to pay its subcontractors is an independent obligation from the State’s obligation to make payments to Contractor. As a result, the State shall have no obligation to pay or to enforce the payment of any monies to any subcontractor.

ARTICLE II

SPECIAL BUDGET DETAIL AND PAYMENT PROVISIONS

1. Orientation and Training Requirements

At the discretion of each institution, Contractor shall ensure that on-site health care service providers complete orientation as specified in Exhibit A – Scope of Work. The parties agree that there will be no reimbursement for orientation/training.

a. On-Site Institution Orientation/Training

Contractor agrees that all providers shall attend on-site orientation and any other required training (i.e.

annual block training and Learning Management System [LMS]) prior to reporting to work at the institution. Orientation/training is designed to assist providers in becoming familiar with the operations of the institution, its medical facilities, and Title 15 of the CCRs that may apply to the institution. To maintain continuity of services and ensure safety for all workers, Contractor shall make available to the institution only those providers who have completed the orientation.

b. Self-Certification Orientation Process

This process may be utilized in place of attending an on-site institution orientation based on institution approval.

(1) Contractor shall obtain a copy of the Health Care On-Site Contractor’s Orientation Handbook from institution and return the signed copy of the CCHCS Orientation Acknowledgement form once complete.

(2) Contractor shall be responsible for ensuring that all providers complete the orientation and sign the Self-Certification Acknowledgement.

(3) Contractor shall maintain the signed copies (new and renewed) of the CCHCS Orientation

Acknowledgement and provide to CDCR/CCHCS upon request.

2. Submission of Invoices/Claims

a. In order to ensure prompt and accurate payment, all invoices/claims shall be submitted according to the applicable directions listed below. It is the responsibility of Contractor to ensure that invoices/claims are sent to the correct address as set forth below according to service type. Invoices/claims sent to

Budget Detail and Payment Provisions Exhibit B

Rev. 7/16/2025 Page 3 of 7 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 invoices/claims must be completed thoroughly, with all applicable fields completed. Invoices/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 invoice/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. Invoices/claims must be legible in order to be considered complete and acceptable for processing or the invoice/claim will be returned and disputed back to Contractor. Disputed/returned invoices/claims shall not be subject to late payment penalties, as set forth in GC Section 927.4.

3. 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/CHCS 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.

e. Claims submitted for payment of on-site Hearing Aid Services and Devices 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 of Hearing Aid Services and Devices shall include all applicable information listed below:

1. Patient’s CDCR number

2. Name of patient

3. Patient DOB

SAMPLE

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

Budget Detail and Payment Provisions Exhibit B

Rev. 7/16/2025 Page 4 of 7

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/hearing aid procedures shall be submitted to the Third Party Administrator at the following address:

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

4. Submission of Invoices

a. Daily Clinic Rate

(1) Contractor may seek reimbursement from CDCR/CCHCS for daily clinic rate for the scheduled date of service. This amount shall only be billed when Contractor and/or Provider conducts clinic as scheduled.

(2) Invoices for daily clinic rate reimbursement cannot be submitted earlier than 30 calendar days after invoice(s) for procedure based billing have been paid. Invoices received earlier than this time frame will not be processed and denied for payment.

(3) Invoices submitted shall include all applicable information listed below:

1. Contractor’s Name

2. Invoice Number

3. Agreement Number

4. Invoice Date

5. Remit Address (Contractor name, mailing address, phone number)

6. Total Invoice Amount

Budget Detail and Payment Provisions Exhibit B

Rev. 7/16/2025 Page 5 of 7

7. Institution and Physical Address

8. List patient(s) names and CDCR number(s) seen on clinic date

9. Date(s) of service

10. Place of service, if different than item 7 above.

11. Contractor Federal Employer Identification Number (FEIN)/Federal Tax ID, if applicable

(4) Invoices shall be submitted via email to the HIS Manual Claims Team at…