SD24-00045_Sample_Contract.pdf

2. The term of this Agreement is:

SAMPLE

California Department of Corrections and Rehabilitation (CDCR)/ Bid Number: SD24-00045 California Correctional Health Care Services (CCHCS) Exhibit A Scope of Work

ORAL AND MAXILLOFACIAL SURGERY SERVICES

1. Introduction/Services

a. This is a statewide Agreement in which Contractor and/or Provider shall provide on-site Oral and Maxillofacial Surgery (OMFS) services to patients referred for such services from California Department of Corrections and Rehabilitation/California Correctional Health Care Services (CDCR/CCHCS). OMFS services include, but are not limited to, the procedures listed or described in Exhibit B-1 – Rate Sheet and Hierarchy Chart and/or Exhibit B-2 – Standardized Fees.

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 OMFS services. “Provider” shall refer to any OMFS Provider who undertakes and renders OMFS services pursuant to this Agreement, as arranged through and/or associated with Contractor as Contractor’s employee, agent, sub-contractor or via any other type of relationship with Contractor. “Provider” includes Contractor with respect to any instance or capacity in which Contractor is or may be acting as an OMFS Provider. Contractor shall ensure that they and all Provider(s) are familiar with this Agreement and will abide by its terms and conditions.

c. The responsibility of CDCR/CCHCS to provide OMFS services is limited to those services which are reasonable and necessary to protect life, prevent significant illness or disability, or alleviate severe pain, and are supported by outcome data as being effective care. For any service or treatment that is nonessential or could safely be deferred until the patient is released from custody, said services shall be so deferred. Any OMFS 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. When prior authorization is required, it must be obtained as specified in Exhibit A-1 Service Specifications. For any service that is provided without the necessary and documented authorization, or which is otherwise not authorized or allowed in accordance with this Agreement, CDCR/CCHCS shall have no obligation to pay for the service.

d. Contractor and/or Provider must be able to perform the tasks associated with providing the above health care services under the scope of their license and assumes full responsibility for the provision of these services. Contractor and/or Provider must be qualified, willing, and able to provide OMFS services and perform any associated tasks in accordance with their professional licensure, which shall be maintained in good standing with the appropriate government agency. Additional required qualifications for each Provider are listed in Exhibit A-1 Service Specifications.

e. Contractor and/or Provider bears the responsibility for providing each OMFS service and performing any associated task in a manner consistent with the commonly accepted standard of care for the subject service. The applicable Dental Standard of Care is care provided in a manner consistent with how a careful, reasonable, and prudent Provider would provide care in the same or similar clinical presentation. 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.

Scope of Work

f. Contractor and/or Provider shall perform services pursuant to the agreement and in accordance with Federal and State laws, rules, regulations, and CDCR/CCHCS policies and procedures. Contractors and/or Providers shall at all times comply with Standard Precautions, CDCR/CCHCS Aerosol Transmissible Disease and Bloodborne Pathogen policies, and maintain CDCR security measures for a safe work environment. Services shall be provided on-site and under the direction of the institution Supervising Dentist (SD), Health Care Services, or designee. Consistent with the above stated responsibilities, Providers are otherwise subject to the oversight and direction of CDCR/CCHCS officials as necessary. For purposes of this Agreement, such CDCR/CCHCS designee must be a civil service employee.

g. CDCR/CCHCS shall make available the standard OMFS instruments, hand pieces, related supplies and materials as necessary for Provider’s use. The Dental staff at the institutions consist of, but are not limited to, Dental Assistants and Supervising Dental Assistants who are available as surgical assistants.

h. Except as otherwise stated in this Agreement, Contractor shall provide and be responsible for all labor, transportation, license(s), permit(s), and every other item of expense necessary or incurred in providing OMFS services, 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 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.

2. Contractor and/or Provider Responsibilities

Services and all requirements as stated below and as required by law shall be provided for contracted services, at the request of the institution SD or designee. The services shall include, but are not limited to the following:

a. Provider must be able to adequately provide services to all institutions awarded on Exhibit

B-1 – Rate Sheet and Hierarchy Chart and any other required documents as stated in Exhibit A-1 – Service Specifications, and as required by law when providing services under this Agreement. Services will be performed only by Providers who meet the requirements outlined in this Agreement. Refer to Exhibit A-1 – Service Specifications for Contractor and/or Provider responsibilities.

b. The institution SD or designee shall approve all Provider(s) of Contractor assigned to the Agreement in advance of services being rendered. If any Provider of Contractor is unable to render services due to illness, resignation, or factors beyond Contractor’s control, Contractor shall immediately submit qualifications of proposed substitute personnel to the institution for approval. The institution shall be notified of any additions or corrections to Contractor’s list of prospective personnel at least five (5) business days before Provider’s start date and Provider shall not start until approval has been received.

c. In the event that Contractor and/or Provider receives notice of dismissal or declination from an institution, and Contractor renders services at another institution, Contractor shall inform that institution SD or designee of notification of the dismissal or declination.

d. Contractor and/or Providers performing irreversible procedures shall follow the Adult

Correctional Dental Care (ACDC) Time Out Protocol.

e. Authorization Requirements

(1) Prior Authorization for Treatment

Excluding emergency care services, any service must have prior authorization in writing from the respective institution SD or designee, in accordance with the institution Dental Authorization Review (DAR) Committee and/or the CDCR/CCHCS Dental Program Health Care Review Committee (DPHCRC). All authorizations shall be documented in the patient’s 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(s). Except for necessary emergency care, CDCR/CCHCS is not obligated to pay for a service that did not have prior authorization, or which is determined by CDCR/CCHCS as not medically necessary, or to have been delivered in a substandard or other inappropriate manner.

(2) Prior Authorization for Transportation/Transfer

CDCR/CCHCS retains full authority to determine whether and how a patient is to be transported between institutions and other health care facilities in relation to receiving any services pursuant to this Agreement.

Contractor and/or Provider have no authority for and shall not attempt to arrange or affect transportation or transfer of a patient to any institution, other health care facility, or provider without prior written authorization from the appropriate institution SD or designee.

(3) 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. Such treatment (unless it is related to specific California legislative provisions) is prohibited under Penal Code, Section 3502, and thus must have prior authorization from the appropriate institution SD or designee. Any service not so authorized, and considered experimental and/or investigational, or otherwise recognized as not being in accord with generally accepted professional dental standards, is prohibited by this Agreement.

f. Other Exclusions and Limitations

(1) Regulations regarding services for patients exclude certain treatments for certain conditions, such as services designated as typically not being medically necessary.

See, California Code of Regulations (CCR), Title 15, Division 3, Chapter 2, Subchapter 2, Article 1, Section 3999.200.

(2) Providers may request approval for an otherwise excluded or limited treatment from the DAR/DPHCRC via the SD or designee, but should do so only if the treatment is determined to be necessary to protect life, prevent significant illness or disability, or alleviate severe pain, and supported by outcome data as being effective care.

(3) Providers may request or recommend approval for treatment of a pre-existing condition(s) from the DAR/DPHCRC via the SD or designee, but should do so only if the service is determined to be necessary to protect life, prevent significant illness or disability, or alleviate severe pain, and supported by outcome data as being effective care.

g. 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:

Name:

Address:

Phone:

Email

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: Kayla Jennings

Address: 8280 Longleaf Drive, Building D Elk Grove, CA 95758

Phone: (916) 691-6866

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.

h. Reports

CDCR/CCHCS reserves the right to request that Contractor and/or Provider submit electronic 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. 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) mailto:m_ContractSupport@cdcr.ca.gov calendar days of request.

i. Additional Reports

CDCR/CCHCS reserves the right to request Contractor provide additional reports or information as needed. The reports requested may include the need for additional information pertaining to Contractor and/or Provider, including but not limited to: name, social security number, date of birth, etc.

The reports shall be submitted in a secure Health Insurance Portability Accountability Act (HIPAA) compliant electronic format (Microsoft Excel 2000 or a more current version) and sent via 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, Building D-2

j. Email Communication

All email communications containing patient protected health information shall be transmitted utilizing a CDCR/CCHCS email address in accordance with Exhibit F – HIPAA Business Associate Agreement.

k. Fit Testing

(1) Upon request from the institution, 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 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.

file:///C:/Users/HCSSDG/AppData/Local/Microsoft/Windows/INetCache/Content.Outlook/N4QGU7O7/m_ContractSupport@cdcr.ca.gov

(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 render on-site direct health care services as arranged with the institution SD or designee upon request, in accordance with each institution’s policies and procedures. Normal hours of clinic operation are Monday through Friday between the hours of 6:00 a.m. and 5:00 p.m. PST.

b. Contractor and/or Provider shall respond to a request for services within the standard one (1) State business day response time unless otherwise stated by the institution.

CDCR/CCHCS may extend the standard response time at the discretion of the institution SD or designee, 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.

c. Contractor and/or Provider shall have a toll-free telephone number and a contact person available by telephone during normal business hours Monday through Friday 8:00 a.m. to 5:00 p.m., PST, for the duration of this Agreement. Telephone answering devices (i.e., message machines) and answering services are not acceptable and their use may be cause for termination of this Agreement.

d. 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/SD or designee, contact lower ranked Contractors in order 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.

4. Responding to a Request for Services

a. Contractor shall respond to the institution request for OMFS services within the stated response time AND submit copies of any current and valid licenses, permits, and/or certifications as stated and required by law, unless already on file with the institution (refer to Exhibit A-1 – Service Specifications, for requirements).

b. A response without the necessary or requested supporting documentation included or already on file as described above may be deemed as non-responsive and the next ranked

Contractor(s) will be contacted.

5. Credential Verification

For OMFS services provided on-site at CDCR institutions, Contractor and/or Provider(s) shall comply with the following credentialing and privileging requirements:

a. Credentialing and Privileging Requirements

For services provided on-site at an institution, Contractor and/or Provider shall comply with all credentialing and privileging requirements:

(1) Contractor shall compile and ensure that its Providers complete the credential and privileging package.

(2) Contractor shall submit a completed MD-App electronic credential and privilege application and associated documentation to CCHCS Credentialing and Privileging Support Unit (CPSU).

(3) Contractor and/or Provider shall comply with all CPSU requirements, policies, and procedures. Services shall not commence until the credentialing process and approval is completed by CPSU.

(4) Contractor shall ensure all Providers possess at all times current and up-to-date credentials and privileges. Contractor shall renew its Providers credentials and privileges every two (2) years by submitting a completed MD-App electronic credential and privilege application, prior to expiration date.

(5) CPSU will notify Contractor once credential and privilege verification has been completed. Upon notification, Contractor shall arrange an effective date for the commencement of services at the institution.

(6) Refer to the Health Care Department Operations Manual for licensure and certification requirements for the appropriate health care service classification requirements. The document is available at:

https://cchcs.ca.gov/policies/

It shall be the responsibility of Contractor to reference this document when services are requested to ensure that any changes in credentialing requirements are met.

6. Scheduling

a. Contractor and/or Provider shall ensure that OMFS services rendered at CDCR institutions have prior authorization in accordance with the most recent version of the Health Care Department Operations Manual (HCDOM) Chapter 3, Article 3, Section

3.3.4.5 Dental Authorization Review (DAR) Committee, as amended, prior to scheduling services.

b. At the time of scheduling, CDCR/CCHCS shall provide Contractor and/or Provider with an https://cchcs.ca.gov/policies/

Scope of Work estimated time the institution anticipates the need for the 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 fluctuations in the CDCR/CCHCS patient population.

c. CDCR/CCHCS shall endeavor to provide five (5) business days’ notice prior to cancellation of Contractor and/or Provider assignment.

d. Contractor and/or Provider shall provide services to institution at a time mutually agreed upon between the institution and Contractor representatives.

7. Cancellation

a. Contractor and/or Provider shall give advanced written notice to the institution SD or designee prior to cancellation of scheduled clinics/services, if for reasons other than illness, as follows:

(1) For scheduled clinics: Seven (7) business days written notice; or

(2) For all other scheduled services: minimum of least twenty-four (24) hours written notice.

b. CDCR/CCHCS may cancel or change assignments by telephone, email and/or fax, without incurring any liability, up to twenty-four (24) hours before Contractor and/or Provider’s scheduled reporting time. If CDCR/CCHCS cancels or changes a requested assignment for any reason, including Emergency Security Situations, such as a lockdown, less than twenty-four (24) hours before a scheduled reporting time, CDCR/CCHCS shall pay a cancellation fee of Fifty Dollars and No Cents ($50.00) per hour for one-half (1/2) Provider’s scheduled clinic hours for that day.

8. Overtime Pay Rate Allowances

No overtime pay rate will be authorized under this Agreement.

9. Holiday Pay Rate Allowances

No holiday pay rate will be authorized under this Agreement.

10. Telephonic Consultations

No telephonic consultations will be authorized under this Agreement.

11. Orientation and Training Requirements

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 in a, b or c below at 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 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. 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.

c. Providers shall have a working knowledge of the institution patient documentation and scheduling software system. The CDCR Adult Correctional Dental Care Program can supply web-based training.

12. Inspections

Inspections shall be carried out by the Adult Correctional Dental Care (ACDC) Headquarters (HQ) Quality Assurance Review, the institution SD or designee, at various times during the Agreement’s term to assess if quality and quantity of OMFS procedures performed meet dentistry standards and determine acceptability and appropriateness of Provider’s work performed.

13. Failure to Perform

a. CDCR/CCHCS shall routinely evaluate the work performance of Provider to determine if

CDCR/CCHCS standards and departmental/institutional policies and procedures are being maintained. Any Provider who fails to meet applicable standards, requirements, policy and procedures or who are deemed physically or mentally incapable of performing the required duties as required by this Agreement shall be excluded from performing future services. The HQ Chief Dentist (CD), institution SD or designee shall state in writing the reason(s) Provider did not meet the required policies or standards and submit a copy to Contractor and to the CCHCS Direct Care Contracts Section (DCCS), Contract Support

Team at: m_ContractSupport@cdcr.ca.gov.

b. The CD, institution SD or designee will forward this information to the CPSU for inclusion in Provider’s credentialing and privileging file as an alert. CDCR/CCHCS shall not pay file://///HCSEGCFILE1/Public$/Plata%20Contracts%20Units/Contract%20Support%20Team/15.%20Oral%20Maxillofacial%20Surgeon/IFB%20Bid%20No.%20SD24-00045%20NEW/Exhibits/m_ContractSupport@cdcr.ca.gov

Contractor for any services performed by its Provider which are deemed unacceptable in accordance with the required services anticipated by this Agreement.

c. Failure to provide services 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. CCHCS DCCS Staff Services Manager III or designee has sole discretion in this decision.

14. California Department of Corrections and Rehabilitation Contact Information

Should questions or problems arise during the term of this Agreement, Contractor should contact the following offices:

a. Billing/Payment Issues:

California Correctional Health Care Services Attention: Healthcare Invoicing Section PO Box 588500 Elk Grove, CA 95758 Phone Number: (916) 691-0699 Email address: m_HISProgramSupport@cdcr.ca.gov

b. Scope of Work/Performance Issues:

Please 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. PST. The institution contract representative or designee shall pre-arrange all needed services to ensure continuity of care and to minimize the disruption of CDCR’s workload.

c. General Agreement Issues:

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

California Correctional Health Care Services (CCHCS) Exhibit A-1 Service Specifications

ORAL AND MAXILLOFACIAL SURGERY SERVICES

1. Contractors and/or Providers Qualifications

a. All Contractors and/or Providers must have the required licenses, permits, and/or certifications as stated below and as required by law; see Provision (2) Licenses, Permits, and Certification Requirements for details.

b. Patient health care is of paramount importance. Accuracy in communications is critical to ensure timely, correct care is provided. Therefore, each provider providing services through this Agreement must be proficient in the English language and be able to communicate effectively with CDCR/CCHCS. All Contractors and/or Providers must be able to speak, understand oral and written communication, and write effectively in the English language.

c. Any Contractor and/or Provider who fails to meet the minimum qualifications shall not be permitted to perform service. The institution Supervising Dentist (SD), Health Program Manager III (HPMIII), or designee shall state in writing the reason(s) Contractor and/or provider does not meet the minimum qualifications and submit to the CCHCS Direct Care Contracts Section, 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 for any additional hours worked identified as not meeting the minimum qualifications.

2. Licenses, Permits, and Certification Requirements

Prior to providing services as outlined in this Agreement, Contractor shall:

a. Ensure that Contractor and each provider referred by Contractor possesses and maintains throughout the term of this Agreement, a valid and current dental license issued by the Dental Board of California and that Contractor and each provider graduated from an American Dental Association (ADA) accredited Oral and Maxillofacial Surgeon program. The provider must be licensed to practice dentistry in the State of California as defined in the Dental Practice Act, Chapter 4, commencing with Section 1600 of the Business and Professions Code. Each Contractor and provider must maintain a current Basic Life Support (BLS) certificate received from the American Heart Association (AHA), the American Red Cross (ARC), American Safety and Health Institute (ASHI), or by a provider approved by the American Dental Association’s Continuing Education Recognition Program (CERP) or Academy of General Dentistry’s Program for Continuing Education (PACE), in accordance with California Code of Regulations (CCR) Title 16 Section 1016(b)(1)(C). Each Contractor and provider must maintain a current Drug Enforcement Agency (DEA) Registration in California to include drug schedules 2, 2N, 3, 3N, 4 and 5 and current access to the Controlled Substance Utilization Review and Evaluation System (CURES).

b. Provide current/renewed licenses, permits, and/or certifications for each provider to the institution SD or designee to be kept on file at the institution throughout the term of this Agreement. Contractor shall ensure that all required licenses, permits, certifications, and any other requirements outlined herein are current and in effect at all times during the term of this Agreement.

mailto:m_contractsupport@cdcr.ca.gov

Service Specifications

c. Provide current/renewed licenses, permits and/or certifications to CDCR/CCHCS not less than thirty (30) calendar days prior to their expiration, in the event the required licenses, permits, and/or certifications are about to expire. If, during the course of this Agreement, any of the licenses and/or requirements are found to be revoked, suspended, inactive, or not in compliance, CDCR/CCHCS may withhold payment for services rendered during the expiration period and/or immediately terminate this Agreement.

d. Assume responsibility for verifying through the appropriate licensing boards that no current or unresolved disciplinary actions have been taken by the State licensing authorities against Contractor or any provider assigned to CDCR/CCHCS, and that all licenses are active and void of misconduct. CDCR/CCHCS may, at its discretion, verify the status of Contractor and/or providers assigned.

3. Contractors and/or Providers Responsibilities

a. Under the direction of the CDCR/CCHCS institution SD or designee, each provider shall render services as permitted within the scope of practice for Oral and Maxillofacial Surgery Services (OMFS) services in accordance with the most recent version of the Health Care Department Operations Manual (HCDOM). Duties/responsibilities shall include, but are not limited to, those listed in Exhibit B-2 – Standardized Fees, which contains three lists of Current Dental Terminology (CDT) codes/procedures. Section one (1) includes procedures requiring only the institution’s Dental Authorization Review (DAR) Committee authorization, section two (2) includes additional procedures requiring approval by both the institution’s DAR Committee and the Dental Program Health Care Review Committee before being performed, and section three

(3) includes procedures never to be approved. For procedures that do not fall under the Exhibit B-2 – Standardized Fees, each Contractor must submit their Usual and Customary Rates (UCRs) Fee Schedule that will be reimbursed at the percentage bid of the zone(s) in which their pre-approved UCR fee of CDT procedure is performed.

b. Provider must be able to perform the tasks associated with providing the above dental services and assumes full responsibility for the provision of these services. All services performed outside the scope of this Agreement will be at the sole risk and expense of Contractor.

c. Provider shall be responsible for ensuring dental equipment brought on-site for performance of the contracted duties meets all regulatory compliance, calibrations, including any requirements for disinfection and sterilization, including the use of Class 5 Steam Sterilization Integrators.

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

d. Provider shall give at least twenty-four (24) hours written notice prior to bringing into the institution any dental/surgical equipment that has not specifically been authorized by CDCR Division of Adult Institutions.

e. Provider shall complete and return all forms required by CDCR/CCHCS regarding treatment of patients.

Service Specifications

f. CDCR/CCHCS shall provide a copy of the CCHCS drug formulary to be kept on file by the provider. Provider shall consult with CDCR/CCHCS dentists to assure that whenever possible, the provider will prescribe only those medications that are on the drug formulary unless the institution SD or designee grants prior authorization for deviation.

g. Provider shall submit a monthly calendar of dates available to conduct on-site OMFS clinics no later than the first day of each month for the following month. Monthly schedules of availability will be submitted via electronic mail to the designated institution representative. Institution representative(s) will contact Contractor or their representative to confirm treatment dates. For a list of CDCR institutions with acronyms, locations, and information, please refer to Exhibit G

– List of Participating CDCR Institutions.

h. Contractor or its provider shall be available to provide OMFS clinics on-site a minimum of one

(1) day per month at each institution within the respective Zone, although scheduling will be based on workload and may not always support one (1) day per month at every institution:

Zone 1 - Pelican Bay State Prison (PBSP);

Zone 2 - High Desert State Prison (HDSP);

Zone 3 - Folsom State Prison (FSP) and California State Prison - Sacramento (SAC);

Zone 4 - San Quentin Rehabilitation Center (SQ);

Zone 5 - California Medical Facility (CMF) and California State Prison - Solano (SOL);

Zone 6 - Mule Creek State Prison (MCSP);

Zone 7 - California Health Care Facility - Stockton (CHCF);

Zone 8 - Sierra Conservation Center (SCC);

Zone 9 - Central California Women's Facility (CCWF) and Valley State Prison (VSP);

Zone 10 - Correctional Training Facility (CTF) and Salinas Valley State Prison (SVSP);

Zone 11 - California Men's Colony (CMC);

Zone 12 - Pleasant Valley State Prison (PVSP) and Avenal State Prison (ASP);

Zone 13 - California State Prison - Corcoran (COR) and California Substance Abuse Treatment Facility and State Prison, Corcoran (SATF);

Zone 14 - Kern Valley State Prison (KVSP), North Kern State Prison (NKSP), and Wasco State Prison (WSP);

Zone 15 - California Correctional Institution (CCI);

Zone 16 - California State Prison - Los Angeles County (LAC);

Service Specifications

Zone 17 - California Institution for Men (CIM), California Institution for Women (CIW), and California Rehabilitation Center (CRC);

Zone 18 - Calipatria State Prison (CAL) and Centinela State Prison (CEN);

Zone 19 - Ironwood State Prison (ISP);

Zone 20 - Richard J. Donovan Correctional Facility (RJD).

4. Acknowledgement of Duties

Contractor

As Contractor, I hereby certify that I have read the above OMFS services – Contractors and/or Providers Qualifications; Licenses, Permits and Certification Requirements; and Contractors and/or Providers Responsibilities and that I understand the duties required to successfully perform the services stated herein.

Printed Name of Contractor Signature Date

Additional provider hired by Contractor

As the provider hired by Contractor, I hereby certify that I have discussed the above OMFS services

– Contractors and Provider(s) Qualifications; Licenses, Permits and Certification Requirements;

and Contractors and Provider(s) Responsibilities with Contractor and that I understand the duties required to successfully perform the services stated herein.

Printed Name of Provider Signature Date

California Correctional Health Care Services (CCHCS) Exhibit B Budget Detail and Payment Provisions

ORAL AND MAXILLOFACIAL SURGERY SERVICES

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 – Rate Sheet and Hierarchy Chart, 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, Division 3, Chapter 1, Subchapter 4, Articles 8 and 9, and CCR, Title 15, Division 3, Chapter 2.

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 – Rate Sheet and Hierarchy Chart 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 in accordance with the terms outlined in Exhibit B-1 – Rate Sheet and Hierarchy Chart. 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.

CDCR/CCHCS Bid Number: SD24-00045 Budget Detail and Payment Provisions Exhibit B

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 the 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. Submission of Invoices

a. In order to ensure prompt and accurate payment, all invoices/claims shall be submitted according to the applicable directions listed below for each service type. 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 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. All invoices/claims shall include the Agreement number and shall not be submitted more frequently than monthly in arrears unless authorized by Healthcare Invoicing Section (HIS) management.

e. Invoices/claims submitted shall include the following information and 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

2. Submission of Claims to the Third Party Administrator Facility and Procedure Based Billing

a. Information concerning claims adjudicated for CDCR/CCHCS by CorrectCare Integrated Health (CCIH) 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 HIS Help Desk at (916) 691-0699 or at:

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

Budget Detail and Payment Provisions Exhibit B

b. Pursuant to the California Prompt Payment Act, GC Section 927 et seq., undisputed claims shall be paid within forty-five (45) days of the date of receipt. Claim billing cycles shall be restricted to sixty

(60) days from original claim submission date or after Contractor has verified the claims are not in the CCIH Web Portal waiting processing. If you do not have access to the CCIH Web Portal, contact the HIS Help Desk at (916) 691-0699 or via 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 a 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 twelve (12) months and/or one (1) 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, (b)(3) First Level Appeal.

e. For any procedures not listed on the Exhibit B-2 – Standardized Fees, Contractor will be reimbursed at their Usual, Customary, and Reasonable (UCR) fees for pre-approved procedure(s) at the percent (%) bid for the zone(s) in which the UCR fee of CDT (Current Dental Terminology) procedure(s) is performed. Contractor's bided percentage of CDCR/CCHCS’s Standardized Fees and rank for each institution zone is noted on the Exhibit B-1 – Rate Sheet and Hierarchy Chart.

(1) Dental Services

(a) Claims submitted for payment of on-site dental services shall be on a 2012 American Dental Association Dental Claim Form or its successor(s) and shall itemize each service provided.

(b) Claims submitted for payment of on-site dental services shall include all applicable information listed below:

1. Name of patient

2. Patient date of birth

3. Patient’s CDCR number

4. Gender of patient

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

6. All required diagnosis codes

7. Date of claim

8. Date(s) of service

9. Place of service

10. All required Current Dental Terminology (CDT)/Procedure Codes (D-codes)

11. Any required CMS codes (if applicable)

12. Tooth number(s) (if applicable)

13. Service units

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

Budget Detail and Payment Provisions Exhibit B

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

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

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

18. 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.)

19. Service facility location information

20. Billing provider information

21. 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.

(c) Claims submitted for on/off-site Procedure Based dental services shall be submitted to the Third Party Administrator at the following address:

CorrectCare Integrated Health PO Box 349026 Sacramento, CA 95834-9026

3. Submission of Invoices

a. Dental Services

(1) Minimum Reimbursement

Contractor may seek a single reimbursement from CDCR/CCHCS for claims processed that do not reach a total daily minimum reimbursement amount combined for services provided at all institutions on the scheduled date of service. If services are provided to more than one institution, Contractor may only invoice based on total paid procedures for the date of service, not per institution clinic. Contractor shall submit a copy of the Explanation of Benefits (EOB) and an invoice that includes CDT code D9410 with the differential, not to exceed the minimum reimbursement amount for that date of service. This amount shall only be billed when Contractor and/or Provider provides services as scheduled and shall not supersede Provision 4, Cancellation Fee below. The minimum reimbursement amount will vary by zone:

(a) Total daily minimum reimbursement amount of $5,300.00 for zones 1, 2, 14 and 15.

(b) Total daily minimum reimbursement amount of $3,300.00 for zones 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 16, 17, 18, 19 and 20.

(2) Invoices for the minimum reimbursement cannot be submitted earlier than thirty (30) calendar days after claim(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 for remaining payment of claims that did not reach the daily minimum reimbursement amount shall include all applicable information listed below:

(a) Contractor’s Name

(b) Invoice Number

(c) Agreement Number

Budget Detail and Payment Provisions Exhibit B

(d) Invoice Date

(e) Remit Address (Contractor name, mailing address, phone number)

(f) Total Invoice Amount

(g) Institution and Physical Address

(h) List full patient name(s) and CDCR number(s) seen on clinic date

(i) Date(s) of service of clinic

(j) Total Amount Paid for Clinic Date

(k) Place of service, if different than item 7 above.

(l) All required Current Dental Terminology (CDT)/Procedure Codes (D-codes)

(m) Total charges for invoice not to exceed minimum reimbursement amount

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

(o) Explanation of Benefits (EOB) for all patients listed on the invoice

(4) Invoices submitted for the daily clinic minimum reimbursement on a date of service that the Contractor held clinics at multiple institutions must split the reimbursement amount evenly across the institutions. Invoices must be billed to the applicable institutions and include the information listed below:

(a) Total Amount Paid for Clinic Date for all institutions

(b) Total remaining amount to be billed to meet daily clinic minimum reimbursement amount

(c) Total amount to be paid per institution

(d) Contractor’s Name

(e) Invoice Number

(f) Agreement Number

(g) Invoice Date

(h) Remit Address (Contractor name, mailing address, phone number)

(i) Total Invoice Amount

(j) Institution and Physical Address

(k) List full patient name(s) and CDCR number(s) seen on clinic date

(l) Date(s) of service of clinic

(m) Total Amount Paid for Clinic Date

(n) Place of service, if different than item 7 above.

(o) All required Current Dental Terminology (CDT)/Procedure Codes (D-codes)

(p) Total charges for invoice not to exceed minimum reimbursement amount

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

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