Attachment A to ITB Maternity Care Program 2008 LETTER OF INTENT TO CONTRACT The provider signing below is willing to enter into a contract with the __ (name of Primary Contractor) _______ as a subcontractor for the provision of covered services to Medicaid eligibles enrolled with the __(name of Primary Contractor)_______. This provider agrees to sign a contract with __ (name of Primary Contractor)_______, if said Primary Contractor is awarded a Medicaid contract beginning October 1, 2008 for __(district #)__ eligibles. Signing this letter of intent obligates the provider to sign a contract with __ (name of Primary Contractor)_______. All subcontractors shall comply with Title VI of the Civil Rights Act of 1964 (42 USC §2000d, et. seq.), Section 504 of the Rehabilitation Act of 1973 (29 USC §6101, et seq.), the Americans with Disabilities Act of 1990 (42 USC §2101, et seq.), and the regulations issued thereunder by the Department of Health and Human Services (45 CFR Parts 80, 84 and 90). No individual shall, on the ground of race, sex, color, creed, national origin, age or disability be excluded from participation in, be denied the benefits or, or be otherwise subjected to discrimination under any program of services. If a As a Delivering Healthcare Professional (DHCP), I have also read and understood understand the DHCP Expectations of the Primary Contractor listed in Attachment 1. As a DHCP, I also understand that I will be required to complete a Primary Contractor Performance “Report Card” survey twice a year. The purpose of and details for completion of this report card survey is are explained in are Attachment 2. ______ (initial) The following information is furnished by the subcontracting provider: 1. Check all that apply: ____ Hospital ____ DHCP ____ Prenatal Care Only ____ Other: specify: ______________________________ 2. Printed Name: _______________________________ NPI: ________________________ 3. Address: _________________________City ____________ State _____ Zip ___________ (where services will be provided) 4. Telephone: ________________ Fax: _______________ Email: _____________________ 5. Counties from which I will take patients: ______________________________________ 6. If DHCP, hospital privileges held at: ___________________________________________ 7. Payment Arrangement: ________________________________________________________ _________________________________ Provider Signature _________________________________ Printed Name/Relation of Signer __________________________________ Date Signed __________________________________ Office Contact
Attachment A to ITB Maternity Care Program 2008 Revised 6/19/08
Attachment A to ITB Maternity Care Program 2008
Attachment 1 DHCP EXPECTATIONS OF THE PRIMARY CONTRACTOR As a subcontracting Delivering HealthCare Professional (DHCP) in the Maternity Care Program, you should expect the following considerations from your Primary Contractor (PC). The relationship between the DHCP and the Primary Contractor is a contractual relationship and in many ways is not specifically governed by the Agency. Each DHCP will need to appoint a representative to participate in a bi-annual conference call with Agency staff to discuss the Maternity Care Program. Negotiation of reimbursement dependent on the array of services performed (e.g. delivery only, prenatal and delivery, anesthesia, etc.); Annual open enrollment for subcontractors; An adequate network of subcontractors to meet patient needs; Timely payment once claims are submitted to the PC. Current standards are within 20 calendar days of Medicaid payment no later than 60 calendar days of delivery with the exception of TPL; Strict Compliance with HIPPA and patient confidentiality standards Implementation and maintenance of Quality Assurance system by which access, outcome and processes are measured on both a program and provider specific basis; Patient choice of DHCP; Community based outreach program to ensure awareness of the Maternity Care Program; A provider education plan (what to expect, how the system works, etc.); To fully explain what services are included in their global payment as well as what services are included in your contractual payment. For example, lab services (other than hemoglobin, hematocrit and u/a) are billable fee-for-service; however cerclages are in the global fee paid to the PC and may or may not be included in your contractual payment; To have a Director to be available, accessible, and/or on-call for any medical or administrative problems which may arise; Prohibition of discrimination against any recipient based on their health status or need for health services; Toll-free telephone service for recipients to ask questions, enroll in the program, etc. An established education plan for recipients to include healthy life styles, planning for the baby, self-care, family planning, appropriate use of the medical system, etc. A grievance procedure for both subcontractors and recipients that is easily accessible and is explained to the recipients upon entry into care; A Care Coordinator assigned to each of your patients to assist with the Medicaid enrollment process, psychosocial issues, education and other needs that may arise; Patients that have completed the Medicaid enrollment process and if not, to have patients assisted in that process.
Revised 6/19/08
Attachment A to ITB Maternity Care Program 2008
Attachment 2
SAMPLE ONLY – NOT TO BE RETURNED WITH LETTER OF INTENT
NOTE: This survey will only be completed by Delivering Healthcare Professionals (DHCPs) Dear DHCP: Please take a moment and rank the performance of PRIMARY CONTRACTOR NAME. The information you provide will allow the Agency to distribute the five (5%) percent holdback payment previously withheld. Three (3%) will be based on your ranking of the Primary Contractor’s performance. Please refer to the Maternity Care Program Operational Manual, Section 11, for details on holdback distribution. You should have a separate survey for each Primary Contractor to which you subcontract. Please return the survey within five days. Surveys may be returned via fax to the Medicaid Agency. Performance in each of the areas should be ranked 1 to 5 based on the following grading: Comments may be added at your discretion. Please know that Primary Contractors will be allowed to dispute the rankings therefore, you should be prepared to defend the ranking provided. 1 - Not Responsive: Primary Contractor never meets requirement 2 - Poor: Primary Contractor sometimes meets this requirement 3 - Adequate : Primary Contractor demonstrates adequate understanding and meets the minimum requirement 4 - Excellent: Primary Contractor has exceeded this requirement on occasion. 5 - Exceptional: Primary Contractor always meets or exceeds this requirement
Comments may be added at your discretion. Please know that Primary Contractors will be allowed to dispute the rankings; therefore, you should be prepared to defend the ranking provided.
Period Covered: ___________________
Total Deliveries Billed to this PC: ________
DHCP or Group Name: ___________________________Contact: _______________________ 1. 2. 3. 4. 5. 6. 7. ____ Payments received according to contract requirements? ____ The PC understands the claim processing and payment process? ____ Was the PC accessible and helpful in dealing with claim payment issues? ____ Was care coordination accessible to your patients? ____ Did the care coordination received by your patients meet program requirements.? ____ Were grievances filed by either yourself or your patients handled in a timely and responsive manner? (NOTE: If no grievances were filed, then a 5 should be awarded) ____ On scale from 1 – 5, with 1 being poor and 5 being exceptional, rank your overall relationship with the PC.
DHCPs will be asked to maintain, and provide as necessary, documentation substantiating the ranking.
Revised 6/19/08