SD26-00005_Sample_Contract.pdf

2. The term of this Agreement is:

SAMPLE

California Department of Corrections and Rehabilitation (CDCR)/ IFB Number: SD26-00005 California Correctional Health Care Services (CCHCS) Exhibit A Scope of Work

ENDODONTIC DENTAL SPECIALTY SERVICES

1. Introduction/Services

a. This is a statewide Agreement in which Contractor and/or Provider shall provide off-site Endodontic Dental Specialty services to patients referred for such services from California Department of Corrections and Rehabilitation/California Correctional Health Care Services (CDCR/CCHCS). On-site services shall only be considered on a case-by-case basis, as determined by CDCR/CCHCS and approved by the Headquarters (HQ) Dental Program. If CDCR/CCHCS determines that on-site services are necessary, the provision of those services shall be mutually agreed upon by both parties. Endodontic dental services include, but are not limited to, the procedures listed or described in Exhibit B-1 – Rate Sheet and/or Exhibit B-2 – Standardized Fees.

b. Endodontists employ advanced imaging techniques and modern technology to diagnose and treat complex dental issues. Their primary focus is the preservation of natural teeth through specialized treatment of the tooth’s interior pulp and root structure. Within the CDCR/CCHCS Adult Correctional Dental Care Program (ACDC), endodontists will provide a limited scope of specialty services, as outlined below. These services are intended to address and manage complications arising from anterior and posterior endodontic dental procedures initiated by dentists at all CDCR institutions.

c. 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 Endodontic Dental Specialty services. “Provider” shall refer to any Endodontic Provider who undertakes and renders Endodontic Dental Specialty 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 Endodontic Provider. Contractor shall ensure that they and all Provider(s) are familiar with this Agreement and will abide by its terms and conditions.

d. The responsibility of CDCR/CCHCS to provide Endodontic Dental Specialty 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 Endodontic Dental Specialty 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.

e. 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 Endodontic Dental Specialty 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.

f. Contractor and/or Provider bears the responsibility for providing each Endodontic Dental Specialty 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 setting.

g. 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 off-site and under the direction of the institution Supervising Dentist (SD) 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.

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 Endodontic Dental Specialty services, including any expense anticipated or incurred by Contractor and/or Provider associated with travel to and from an institution for on-site services. 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 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. Authorization Requirements

(1) Prior Authorization for Treatment

Excluding emergency care services, any service must have prior authorization in

Scope of Work 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 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.

c. 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.SAMPLE

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: Statewide Dental Program Name: Bradley Archibald, DDS Address: 8220 Longleaf Dr. Building B, Elk Grove, CA 95758

Phone: (916) 430-7084 Email Bradley.Archibald@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 Services Team

Name: Kayla Jennings Address: 8280 Longleaf Drive, Building D

Phone: (916) 691-6866 Email m_ContractSupport@cdcr.ca.gov

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

e. 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) calendar days of request.

f. 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

SAMPLE

mailto:Bradley.Archibald@cdcr.ca.gov mailto:m_ContractSupport@cdcr.ca.gov

Scope of Work 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 Elk Grove, CA 95758

g. Email Communication

All email communications containing patient protected health information shall be sent via encrypted email.

3. Mutually Agreed On-site Services

a. On-site services shall only be considered on a case-by-case basis, as determined by CDCR/CCHCS and approved by the HQ Dental Program. If CDCR/CCHCS determines that on-site services are necessary, the provision of those services shall be mutually agreed upon by both parties.

b. CDCR/CCHCS shall make available basic endodontic instruments, handpieces, and related supplies and materials necessary for mutually agreed upon on-site 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 endodontic assistants.

c. For mutually agreed upon on-site services, Contractor and/or Providers performing irreversible procedures shall follow the Adult Correctional Dental Care (ACDC) Time Out Protocol.

d. Before providing mutually agreed-upon on-site services, Contractor shall obtain the Health Care On-Site Contractor’s Orientation Handbook from the institution. Contractor and/or Provider shall:

i. Comply with all requirements in the handbook; and

ii. Upon completing the required review of the Handbook, sign and return the CCHCS

Orientation Acknowledgement form.

e. Providers shall have a working knowledge of the institution patient documentation and scheduling software system when pre-approved to provide on-site services. The CDCR Adult Correctional Dental Care Program can supply web-based training.

4. Request for Services

a. Contractor and/or Provider agrees to render off-site direct health care services as arranged with the institution SD 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 and/or email during normal business hours, Monday through Friday (excluding holidays), 8:00 a.m. to 5:00 p.m. (PST) for the duration of the

Scope of Work

Agreement. Telephone answering devices (i.e., message machines) and answering services are not permitted. 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/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.

5. Responding to a Request for Services

a. Contractor shall respond to institution request for services within the standard response time of three (3) business days, unless otherwise stated by CDCR/CCHCS.

CDCR/CCHCS may extend the response time, at the discretion of the institution CEO/SD 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 CEO/SD or designee request for documentation, which may include but not be 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 other Contractor(s) will be contacted.

6. Scheduling

a. Contractor and/or Provider shall ensure that all Endodontic Dental Specialty services 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. CDCR/CCHCS shall notify Contractor and/or Provider when services are anticipated to be provided. 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 appointment.

7. Cancellation

a. Contractor and/or Provider shall give advanced written notice of at least twenty-four (24) hours to the institution SD or designee prior to cancellation of scheduled services, if for reasons other than illness.

b. Due to institutional operational factors and security conditions that may restrict patient movement, off‑site medical appointments may, at times, be delayed or cancelled.

CDCR/CCHCS may cancel or modify scheduled appointments by telephone, email, and/or fax up to twenty‑four (24) hours prior to the scheduled reporting time without incurring liability. If CDCR/CCHCS cancels or modifies an appointment less than twenty‑four (24) hours before the scheduled appointment time, upon mutual agreement between CDCR/CCHCS and the Contractor, CDCR/CCHCS shall pay a cancellation fee of no more than Fifty Dollars ($50.00) for each scheduled appointment hour.

8. Telephonic Consultations

No telephonic consultations will be authorized under this Agreement.

9. Orientation Requirements

a. Self-Certification Orientation Process

All off-site providers shall complete the below process, prior to rendering services. All parties agree that there will be no reimbursement for providers to complete the Self- Certification Orientation Process.

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

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

Orientation Acknowledgement and provide to CDCR/CCHCS upon request.

10. Inspections

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

11. 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), Regional Dental Director (RDD) 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 Services Team at: m_ContractSupport@cdcr.ca.gov.

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

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

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 Manager II or designee has sole discretion in this decision.

12. 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 H – 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 Services 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

ENDODONTIC DENTAL SPECIALTY 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 Chief Dentist (CD) 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 Services 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 Endodontics 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 CD, CCHCS Credentials Verification Unit, 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

California Department of Corrections and Rehabilitation (CDCR)/ IFB Number: SD26-00005

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 Endodontic Dental Specialty 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. 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 region(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 endodontic dental specialty services and Contractor and Provider assume 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 complete and return all forms required by CDCR/CCHCS regarding treatment of patients.

d. 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 the provider will prescribe only those medications that are on the drug formulary unless the institution SD or designee grants prior authorization for deviation.

e. Institution representative(s) will contact Contractor or their representative to confirm treatment dates.

f. Contractor and/or Providers are expected to manage endodontic complications listed below:

(1) Instrument Separation: Retrieval or bypassing of broken instruments using microscopy and ultrasonic techniques.

(2) Ledge Formation & Canal Blockages: Renegotiation, bypassing, or removal of ledges to re-establish apical patency.

(3) Perforations: Sealing of coronal, furcation, or root perforations, with bioceramic materials.

California Department of Corrections and Rehabilitation (CDCR)/ IFB Number: SD26-00005

Service Specifications

(4) Missed Canals: Identification and treatment of canals not addressed during initial therapy.

(5) Overfilling/Underfilling: Correction of obturation deficiencies, including removing excessive filling material and retreatment when indicated.

(6) Tissue Injury: Management of tissue injuries caused by medicaments, lubricants, or irrigating solutions expressed beyond the root apex.

(7) Persistent Infection: Nonsurgical endodontic treatment of chronic apical periodontitis and other advanced endodontic infections.

California Department of Corrections and Rehabilitation (CDCR)/ IFB Number: SD26-00005 California Correctional Health Care Services (CCHCS) Exhibit B Budget Detail and Payment Provisions

ENDODONTIC DENTAL SPECIALTY 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, 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 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. 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 IFB Number: SD26-00005 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/Claims

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 below information and must be typed legibly 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/

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 Third Party Administrator (TPA) will provide an explanation regarding 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 region(s) in which the UCR fee of CDT (Current Dental Terminology) procedure(s) is performed. Contractor's bid percentage of CDCR/CCHCS’s Standardized Fees and rank for each institution region is noted on the Exhibit B-1 – Rate Sheet and Hierarchy Chart.

(1) Dental Services

(a) Claims submitted for payment of 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 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. Tooth number(s) (if applicable)

12. Service units

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

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

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

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

17. 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.)

18. Service facility location information

19. Billing provider information

20. 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. Cancellation Fee

a. Contractor shall submit an invoice for cancellation fee reimbursement of a cancellation fee for mutually agreed upon on-site appointment or off-site appointments that were cancelled less than 24 hours prior to the scheduled appointment.

b. Invoice submitted for cancellation fee reimbursement must be typewritten, legible, complete and accurate in order to be considered acceptable for processing or invoices will be denied and returned to Contractor for correction.

c. Invoices submitted for the cancellation fee shall include all applicable information listed below:

(1) First and Last name of Contractor or Provider performing services

(2) Invoice Number

(3) Agreement Number

(4) Invoice Date

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

(6) Types of services or Contractor or Provider’s classification

(7) Institution where services were scheduled to be performed

(8) Date(s) of scheduled off-site or on-site clinic

(9) Scheduled off-site or on-site clinic hours

(10) Reason(s) for the cancellation

(11) Documentation to support the scheduled clinic and cancellation

(12) Total Amount of Cancellation Fee

d. Invoices shall be submitted via email to the HIS Manual Claims Team at m_HISManualClaims@cdcr.ca.gov. If email submittal is not available, invoices may be mailed to the following address:

California Correctional Health Care Services Healthcare Invoicing Section Attention: Manual Claims Team mailto:m_HISManualClaims@cdcr.ca.gov

Budget Detail and Payment Provisions Exhibit B

PO Box 588500, Building D-2 Elk Grove, CA 95758

4. Rejection of Contractor’s Invoice/Claim

CDCR/CCHCS reserves the right to reject a Contractor’s invoice/claim if Contractor fails to submit the invoice/claim in the appropriate format or within the appropriate time frame specified within this Agreement. Disputed invoices/claims will be returned to Contractor without payment and will include an explanation of the invoice/claim dispute. Contractor will have the right to appeal or otherwise resubmit the invoice/claim with the pertinent documentation to the address below. Disputed/returned invoices/claims shall not be subject to late payment penalties, as set forth in GC Section 927.4.

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

For all other services California Correctional Health Care Services Healthcare Invoicing Section Attention: Manual Claims Team PO Box 588500, Building D-2

5. Invoice/Claim Audits and Refunds

CDCR/CCHCS has the right to review invoices/claims retrospectively to ensure invoices/claims were processed correctly and per the contract terms. Should CDCR/CCHCS determine that either invoices, claims, or both resulted in an overpayment; CDCR/CCHCS shall request a refund in the incorrect dollar amounts. The Contractor shall refund any monies found from these retrospective audits. Contractor shall refer to Exhibit D – Special Terms and Conditions & Additional Provisions, Section 63 for specific information regarding overpayments.

6. Invoice/Claim Payment Inquiry

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

7. Healthcare Invoicing Section (HIS) Help Desk

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

California Department of Corrections and Rehabilitation (CDCR)/ California Correctional Health Care Services (CCHCS) Rate Sheet

IFB Number: SD26-00005 Exhibit B-1

ENDODONTIC DENTAL SPECIALTY SERVICES

Contractor must be able to provide services to all institutions awarded below. Subcontractors may be required to comply with the terms of this Agreement. If subcontractors are used, subcontractor information must be submitted. If additional subcontractors are added during the term of the contract, an updated subcontractor/consultant list must be submitted.

Contractors with multiple Agreements for the same service at the same institution shall be obligated to provide service(s) at the rate specified in Contractor’s primary Agreement (i.e., Agreement resulting from the prior bid) until all obligations under that Agreement (e.g., rate per procedure) are satisfied before the rate in any subsequent Agreement(s) can be used. The only exception to this provision occurs when the rate in a subsequent Agreement is lower than those of the primary Agreement; the State then has the sole right to determine which rate will be applied. The rates listed below are in effect for the term of the Agreement, including any extension of the term through a formal amendment.

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

REGION 1

California Medical Facility (CMF), California State Prison – Sacramento (SAC), San Quentin Rehabilitation Center (SQ), California State Prison – Solano (SOL), Folsom State Prison (FSP), High Desert State Prison (HDSP), Mule Creek State Prison (MCSP), Pelican Bay State Prison (PBSP).

Bid Rate Cap Percent (%) Bid of

CDCR/CCHCS Standardized Fees.

120%

REGION 2

California Men's Colony (CMC), Central California Women's Facility (CCWF), Correctional Training Facility (CTF), Salinas Valley State Prison (SVSP), Sierra Conservation Center (SCC), Valley State Prison (VSP), California Health Care Facility (CHCF), Pleasant Valley State Prison (PVSP).

Bid Rate Cap Percent (%) Bid of

CDCR/CCHCS Standardized Fees.

120% SAMPLE

CDCR/CCHCS

Rate Sheet

IFB Number: SD26-00005 Exhibit B-1

REGION 3

Avenal State Prison (ASP), California Correctional Institution (CCI), California State Prison – Corcoran (COR), California State Prison – Los Angeles County (LAC), California Substance Abuse & Treatment Facility (SATF), Kern Valley State Prison (KVSP), North Kern State Prison (NKSP), Wasco State Prison (WSP).

Bid Rate Cap Percent (%) Bid of

CDCR/CCHCS Standardized Fees.

120%

REGION 4

California Institution for Men (CIM), California Institution for Women (CIW), Calipatria State Prison (CAL), Centinela State Prison (CEN), Ironwood State Prison (ISP), Richard J. Donovan Correctional Facility (RJD).

Bid Rate Cap Percent (%) Bid of

CDCR/CCHCS Standardized Fees.

120%

In accordance with Exhibit A – Scope of Work, Section 7 – Cancellation, payments will be as follows:

Due to institutional operational factors and security conditions that may restrict patient movement, off‑site medical appointments may, at times, be delayed or cancelled. CDCR/CCHCS may cancel or modify scheduled appointments by telephone, email, and/or fax up to twenty‑four (24) hours prior to the scheduled reporting time without incurring liability. If CDCR/CCHCS cancels or modifies an appointment less than twenty‑four (24) hours before the scheduled reporting time, CDCR/CCHCS shall pay a cancellation fee of no more than Fifty Dollars ($50.00) for each scheduled appointment hour.

California Correctional Health Care Services (CCHCS) Exhibit B-2 Standardized Fees

ENDODONTIC DENTAL SPECIALTY SERVICES

All non-emergency services utilizing Code of Dental Procedures and Nomenclature (CDT) codes not listed within this document must be approved by both Institution's Dental Authorization Review Committee (DAR) and Dental Program Health Care Review Committee (DPHCRC).

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 region(s) in which the UCR fee of CDT (Current Dental Terminology) procedure(s) is performed.

Procedures Requiring Only DAR Approval

CDT

Code

Nomenclature (Description) Fee

D3310 Endodontic therapy, anterior tooth (excluding final restoration) $1,425.00

D3320 Endodontic therapy, premolar tooth (excluding final restoration) $1,575.00

D3330 Endodontic therapy, molar tooth (excluding final restoration) $1,850.00

D3331 Treatment of root canal obstruction; non-surgical access $700.00

D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth

$275.00

D3333 Internal root repair of perforation defects $525.00

D3346 Retreatment of root canal filling - anterior $1,750.00

D3347 Retreatment of root canal filling - premolar $1,900.00

D3348 Retreatment of root canal filling - molar $2,175.00

D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.)

$500.00

D3352 Apexification/recalcification - interim medication replacement $312.00

D3353 Apexification/recalcification - final visit (includes completed root canal therapy)

$725.00

D3410 Apicoectomy - anterior $1,800.00

D3421 Apicoectomy - premolar (first root) $1,950.00

D3425 Apicoectomy - molar (first root) $2,275.00

D3426 Apicoectomy - (each additional root) $500.00

D3430 Retrograde filling - per root $425.00

D3950 Canal preparation and fitting of preformed dowel or post $425.00

D0140 Limited oral evaluation - problem focused $165.00

D0220 Intraoral - periapical first radiographic image $55.00

D0230 Intraoral - periapical each additional radiographic image $45.00

D0364 Cone beam CT capture and interpretation with limited field of view

- less than one whole jaw

$450.00

D0380 Cone beam CT image capture with limited field of view - less than one whole jaw

$350.00

California Correctional Health Care Services (CCHCS) Exhibit B-2 Standardized Fees

D0461 Testing for cracked tooth $150.00

D9110 Palliative (emergency) treatment of dental pain - minor procedure $250.00

If CDCR/CCHCS cancels or modifies an appointment less than twenty‑four (24) hours before the scheduled appointment time, upon mutual agreement between CDCR/CCHCS and the Contractor, CDCR/CCHCS shall pay a cancellation fee of no more than Fifty Dollars ($50.00) for each scheduled appointment hour.

Any radiology and/or diagnostic imaging services provided by CDCR/CCHCS are not reimbursable by the Contractor under this Agreement.

In accordance with Exhibit B – Budget Detail and Payment Provisions, Contractor shall be reimbursed for the above pre-approved CDT procedure(s) under the following payment provisions:

1. CDCR/CCHCS reserves the right to subject Contractor’s submitted invoices(s)/claims(s) to a pre-payment review and post-payment retrospective audit.

2. If a pre-payment review is conducted by a CDCR/CCHCS endodontist who determines that

Contractor’s submitted invoice(s)/claims(s) contain CDT coding error(s), those submitted invoices/claims containing CDT coding errors will be denied. Contractor shall resubmit corrected invoices(s)/claims(s) for review and payment.

3. If a post-payment audit by a CDCR/CCHCS endodontist has determined that Contractor’s submitted invoice(s)/claim(s) was found to contain CDT error(s), CCHCS Healthcare Invoicing…