Docstoc

SUBCONTRACT

Document Sample
SUBCONTRACT Powered By Docstoc
					                   EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                        FY 2010-2011
                                       Page 1 of 13

This contract is entered into between The Health Planning Council of Southwest Florida, Inc., hereinafter
referred to as the “H.P.C.” and, «Business» «Firstname» «Lastname» hereinafter referred to as the
“Provider”.

THE PARTIES AGREE:
 I. THE PROVIDER AGREES:
  A. To refer all potentially eligible children to Early Steps of Southwest Florida, hereinafter referred to
     as “Early Steps of SWFL” within two (2) days of initial contact with the family in accordance with
     federal Child Find requirements for Individuals with Disabilities Education Act hereinafter
     referred to “IDEA”, Part C, herein incorporated by reference. Parental notification and consent for
     referral is encouraged.

   B. To perform the appropriate Early Steps of SWFL contracted services as specified on
      Attachment I: Provider Check List.

   C. To provide services, which meet Florida’s Department of Health hereinafter referred to as “FDOH”
       standards, defined in the H.P.C.’s contract with FDOH. The Provider will comply with the
       standard contract provisions. The Provider hereby acknowledges review of the H.P.C.’s contract
       with FDOH, a copy of which is housed at the Health Planning Council of Southwest Florida,
       Inc.’s office, 8961 Daniels Center Drive, Suite 401, Fort Myers, Florida 33912,
       telephone 239 433-6700. The terms of which are hereby incorporated by reference.

   D. To provide services to eligible clients in Lee, Collier, Hendry and Glades Counties.

   E. To provide services for Part C eligible infants and toddlers ages birth through age two (2) in
      accordance with provisions of the Early Steps Policy Handbook and Operations Guide (PHOG),
      including all appendices and officially dated updates, hereby incorporated by reference. The
      Provider hereby acknowledges review of the PHOG, a copy of which is housed at the Health
      Planning Council of Southwest Florida, 8961 Daniels Center Drive, Suite 401, Fort Myers, FL
      33912 telephone 239-433-6700, and is available on-line at http://www.cms-
      kids.com/home/resources/es_policy_0710/es_policy.html. This document delineates the delivery
      standards, procedures, and requirements for the State of Florida Early Steps Program. It is the
      Provider’s responsibility to read said Guidelines.

   F.   To document each encounter/service provided to an eligible child/family member in the child’s
        treatment record, including date, beginning and ending time, and provider signature, and to
        maintain client records for five (5) years, (in accordance with the State of Florida Children’s
        Medical Service Program Office stated in the H.P.C. Contract) including after this agreement is
        terminated.

   G. To adhere to the established Part C Procedural Safeguards, and Complaint Procedures through
      which families may present grievances about the operation of the service program. Provider will
      advise families of these safeguards and of their right to a fair hearing in these respects. Whenever
      an applicant or family requests a fair hearing, the Provider will provide the family with a copy of
      the Early Steps Summary of Family Rights brochure.
      (Attachment II).

The Health Planning Council of Southwest Florida, Inc.                         Provider Contract 2010-2011
                   EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                        FY 2010-2011
                                       Page 2 of 13

   H. To assist in developing an Individualized Family Support Plan (IFSP) (utilizing assessment tools,
      approved by the State of Florida Early Steps Program, Florida Diagnostic Learning Resource
      System, hereinafter referred to as “FDLRS” and/or the school district) and performing regular
      assessments, PSP Updates, Plans of Care to the family and members of the child’s team, and
      monthly written status progress reports of the same.

   I.       Maintain a minimum of One Million in comprehensive professional liability insurance and
            provide a copy to the State Program Office and local Early Steps Office.

   J    To neither assign the responsibility of this agreement to another party nor subcontract for any of
        the work contemplated under this agreement without prior written notification to H.P.C. Any
        assignment or subcontract for the work contemplated under this agreement must be expressly
        subject to the provisions of this agreement. In the event of a conflict between the terms of an
        agreement of assignment or subcontract and this agreement between H.P.C. and Provider, this
        agreement will control. Additionally, any assignment or subcontract does not affect or reduce
        Provider’s obligations thereunder, which shall continue in full effect to the same extent as though
        no assignment or subcontract had been made.

   K. To ensure all Licensed Health Care Professionals and Infant/Toddler Developmental Specialist’s
      personnel providing direct services to children/families are enrolled in the CMS statewide
      provider database and approved by the CMS State Provider Enrollment Office. Provider will have
      submitted their Medicaid Application and obtained Medicaid Provider status prior to receiving
      referrals.

   L. To provide the H.P.C with a copy of its annual financial and compliance audit (this is a
      requirement only if the Provider receives in excess of Five Hundred Thousand Dollars
      ($500,000.00) annually in Early Steps of SWFL funds).

   M. To provide only those services authorized on the Individualized Family Support Plan (IFSP) and
      only at the frequency, intensity and duration indicated on the IFSP and to serve on the child’s team
      as an active participant from referral to transition from the program. To begin services NO
      LATER than 30 days after service authorization on the IFSP.

    N. To ensure that records contain evidence that Medicaid or Third Party Insurance services (except,
       ITDS,behavior, mental health, vision, and hearing) are properly authorized by the child's primary
       care physician (if HMO or Medipass) or other Licensed Health Care Provider (regular Medicaid or
       Insurance) as appropriate, prior to beginning services.

   O. To accept the payment rate as established by the State of Florida Agency for Health Care
      Administration, the Florida Department of Heath, and/or Early Steps of SWFL (Attachment IIIa)

   P.   To ensure that payment in excess of the Medicaid or CMS/Early Steps program payment rate is
        not requested from the family or the H.P.C.




The Health Planning Council of Southwest Florida, Inc.                         Provider Contract 2010-2011
                   EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                        FY 2010-2011
                                         Page 3 of 13

   Q. To submit a monthly report of all services provided by the Provider to an eligible child/family
      member on the Interventions, Appointments and Referral Form (IAR) (Attachment IIId) by the
      15th day of the month following service delivery, with the exception that the June invoice will
      be submitted no later than July 5, 2010. To provide a final invoice for the fiscal year to HPC
      no later than July 15, 2010.

   R. To verify current third party insurance or Medicaid coverage for eligible children being served and
      report any changes to the H.P.C. To immediately inform Early Steps of SWFL if Provider
      becomes aware of the availability or loss of insurance coverage of an Early Steps of SWFL
      child.

   S.    To bill any identified third party payer within sixty (60) days of date of service according to the
         terms and conditions of said payer source, and to report the intervention to HPC with the regular
         monthly invoice.

   T. To provide access to client files and financial records as requested to satisfy audit and monitoring
      requests.

   U. To notify the H.P.C. and the family of eligible children currently served of staff changes, gaps in
      service of more than one week, and/or closings at least two (2) weeks prior to said change.

   V. To notify Early Steps of SWFL in the event that the provider is suspended or other action is taken
      which could result in the loss of privilege to provide services.

   W. The provider will comply with the Health Insurance Portability Accountability Act (HIPAA) in
      all regulations promulgated thereunder.

   X Quality Assurance
      All providers will receive at least one on-site visit per year to review security policies, client files
      and financial records. In addition each provider will receive an on-site observation while providing
      services for quality assurance monitoring. A record of these visits (attachment IIIi) will be kept in
      the provider file at HPC.

   Y     Minimum Provider Training:
         All Providers will provide the H.P.C. with documentation of completion of all (1) Mandatory State
         of Florida Early Steps Orientation Modules within Ninety (90) days after Modules have been
         offered by the State Program Office (2) Completion of annual HIPAA training, (3) the attendance
         of twelve (12) hours of early intervention related continuing education per year.

   Z      Provider Billing:
        1. Primary Service Provider Travel:
           Reimbursement for IFSP authorized Primary Service Provider travel will be determined as
           follows:
            Providers may bill for travel when a child is seen either at home, childcare center or other
              natural environment specified on the IFSP. Providers will submit a travel log (Attachment III-
              b) along with the IAR. Providers will use one Travel Log form per day. The log will
              contain the name of each child and complete address including the zip code.
The Health Planning Council of Southwest Florida, Inc.                           Provider Contract 2010-2011
                   EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                        FY 2010-2011
                                       Page 4 of 13

              The travel reimbursement is capped at 60 minutes per visit.
              Travel will be reimbursed at the rate of Fifty Cents (.50) per minute units.
              Reimbursement will be computed by adding the total billable monthly minutes per child/visit.
              Beginning/ending reimbursement will be calculated from the Agency office. Individual
               providers may designate their home as the Agency office. Providers will designate the
               complete address of their Agency office, and will utilize and maintain documentation of Map
               Quest minutes when calculating beginning/ending reimbursement along with their Travel
               Log.

        2. Interdisciplinary Assessment: Team Travel
           Travel time begins upon arrival at the designated meeting site, or, at the first evaluation and ends
           at arrival back to the designated meeting site. Team members must travel together to bill
           team travel. Team members will sign an IAR form for each Assessment and assign a Team
           Supervisor. The Team Supervisor completes all IAR’s and submits to the Data specialist
           along with a copy of the BDI-2 face sheet and insurance form (if required) within 5
           business days. Each professional involved in the assessment will keep a copy of the IAR to
           submit with their monthly invoice (attachment IIIa). For the professional transporting the
           entire team, travel will be reimbursed at the state rate of 50 cents (0.50) per minute. Travel
           mileage to the assigned meeting site will be paid to team members willing to go to Hendry and
           Glades counties from Lee, Collier and Charlotte Counties. Mileage and time travel will be
           paid using Map Quest to and from the Provider Agency office and/or the designated
           meeting site. Non-permanent team members such as Floating Team members or Specialist’s
           must obtain approval from the Early Steps of SWFL’s Program Director to bill for participation
           in an Assessment.

   3.    Invoice Requirements:
         All invoices must be submitted with the following documentation:
            Early Steps of SWFL Monthly Provider Invoice (Attachment III-a)
            Monthly Provider Team Status Report for each child (Attachment III-c)
            IAR form correctly completed. (One per child) (Attachment III-d)
            Natural Environment Travel Log. (Attachment:III-b)
            IFSP participation form (Attachment III-f) if applicable
            Consultation amongst Provider form (Attachment III-g) if applicable
            Third party insurance denials and/or Medicaid denials must be submitted when billing part C
              for a child who is otherwise insured.
            Third party insurance denials and/or Medicaid denials may be held for the 13th invoice due
              July 15, 2010 if not submitted within 120 days of date of service.
            The detailed invoice must contain all required information specified by the H.P.C. Billing
              Department. Training of billing procedures will be offered at least twice (2) per year
            The Request for Reimbursement/IAR Forms from the Provider must be received by the 15th
              day of the month following service delivery, and upon inspection and approval of same, the
              H.P.C. will process said invoice for payment. Payment may be delayed if written reports and
              all paperwork have not been received as identified in this contract. If the invoice and required
              documentation is not received within 60 days of date of service, the invoice will not be paid.
            Insurance and/or Medicaid must be billed first, if applicable, as Part C is the payer of last
              resort. Providers must report all services regardless of the payer source. All invoices for
The Health Planning Council of Southwest Florida, Inc.                            Provider Contract 2010-2011
                    EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                         FY 2010-2011
                                        Page 5 of 13

               denied third party insurance and/or Medicaid claims must be submitted with valid EOB’s
               within 120 days of the date of service. Any payment made to the Provider for a service,
               which is subsequently reimbursed by a third party payer source, must be refunded to
               the H.P.C./Early Steps of SWFL. Payment will not proceed unless and until the
               data/invoice is submitted with all data required by the State of Florida’s Early Steps Data
               System. Improperly submitted invoices will be returned to the Provider for correction. The
               Provider will be granted ten (10) days from the date the invoice is returned to them, to
               resubmit a proper invoice.

   4.     Cycle:
          The Provider will submit an invoice by the end of business day on the fifteenth (15th) day of the
          month. The June invoice will be submitted no later than July 5, 2011 and the final 13th invoice no
          later than July 15, 2011.

   5.     Maximum Insurance & Medicaid for required Part C services:
            The federal IDEA Part C legislation mandates that Part C be the payer of last resort
           Families must utilize their insurance or HMO Medicaid providers.
            The family may choose not to have their insurance accessed only when: (A). Use of insurance
        would significantly decrease available lifetime coverage or decrease any other insured benefit(s). (B). Use of
        insurance would increase premiums or lead to the discontinuation of insurance.
             Families may NOT request a waiver from accessing their insurance:
              A. In order to “save” benefits until after the child turns three years of age.
              B. When the family is enrolled in the Medicaid program and the service is a Medicaid billable
                  service.
              C. When the child is enrolled only in the DEI component of Early Steps
              D. When the child is enrolled in the CMS Network
             Providers must inform Early Steps of SWFL within five (5) working days in the event that a
              child becomes ineligible for Medicaid. The Team service coordinator will pursue the reason
              for denial with the family and assist with Medicaid renewal eligibility.
             Providers must notify Early Steps of SWFL within five (5) working days in the event that
              insurance coverage for a service discontinues.

   6.     Timeliness and Accuracy of Required Reports:
          H.P.C. reserves the right to delay or deny payment of any invoice for which required data or
          reports are not submitted within the timeframes of this contract. Provider will submit accurate
          reports and/or data as required. In the event incorrect data is submitted, the H.P.C. is authorized to
          follow-up and resolve incorrect data received from Provider, including, but not limited to, such
          data as unauthorized services, discrepancies in number of units of service or inappropriate rates,
          prior to the release of any payment.

   7      Risk Sharing Policy:
          Early Steps of SWFL will designate a monthly expenditure cap for Part C required Services. The
          monthly expenditure will be 1/12th of the total direct services budgeted amount. If the total of
          valid monthly Part C invoices received from all Providers of required services exceeds the


The Health Planning Council of Southwest Florida, Inc.                                  Provider Contract 2010-2011
                   EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                        FY 2010-2011
                                       Page 6 of 13

        monthly Part C funds available to the H.P.C. for required services, the Providers will receive a
        decreased reimbursement for travel services only calculated on the percentage of the Provider’s
        valid and timely invoice total for travel services only, compared to the total of all Provider’s
        timely and valid invoices received by the invoice cutoff for travel services only for the month the
        funds are available. The decrease will be shared equitably for travel services only among all
        Providers. Untimely, invalid invoices for that month will be held until June 2011, or until the first
        month of available funds that do not jeopardize full payment of timely, valid invoices.

   8    13th Invoice
        At the end of the fiscal year, any funds owed to Providers will be paid to Providers using a
        formula based on the relationship each individual provider’s gross valid timely invoices bears to
        the total of all Part C required services provided. In no case shall a Provider be reimbursed for
        more than one hundred per cent (100%) of gross valid invoices. Payment of 13th invoices will be
        prioritized as follows:

        a. Valid June invoices received after July 5, 2011

        b. Insurance/Medicaid Denial invoices submitted no later than July 15, 2011 Insurance denials
           will be considered for payment after payment of the June, 2011 invoices. Insurance or
           Medicaid denials will be considered only if the Provider has reported data to Early Steps of
           SWFL on insurance/ Medicaid services within thirty (45) days of the date of service and billed
           Insurance and/or Medicaid within 60 days of the date of service.

        c.   If Part C funds have not been exhausted, the following obligations will be paid as prioritized
             until funds are exhausted:

                 1.       Risk Share payments owed to Providers for travel services only

                 2.       Invoices submitted late or inaccurately presented.

                 3.       Insurance/Medicaid denials where data on services have not been provided to Early
                          Steps of SWFL within thirty (30) days and billed within sixty (60) days.

  II. THE HEALTH PLANNING COUNCIL OF SOUTHWEST FLORIDA, INC. AGREES:
   A. Payment Rate:
      To pay for authorized services according to the terms and conditions identified on the eligible
      child’s Individualized Family Support Plan (IFSP), subject to the availability of funds. Rates may
      be adjusted during the authorization period based on changes determined by the State of Florida
      Children Medical Service Program Office and Early Steps of SWFL. The current fee schedule is
      provided as Attachment III-a. Provider understands and is in agreement that the funding for
      payment to Provider thereunder is provided by the State of Florida. The H.P.C.’s performance and
      obligation to pay under this agreement is contingent upon the availability of funds provided by the
      State of Florida as referenced herein. The costs of services paid under any other contract or from
      any other source are not eligible for reimbursement under this contract.

   B. Contract Payment/Data:
     1. The Provider will record all services provided under the auspices of Early Steps of SWFL and
        the Early Steps Program Data System, as required by the State of Florida Department of Health
The Health Planning Council of Southwest Florida, Inc.                           Provider Contract 2010-2011
                   EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                        FY 2010-2011
                                       Page 7 of 13.

           and Early Steps, whether or not funding is requested. The H.P.C. will enter this data in the Early
           Steps statewide data system to comply with federal data reporting requirements. Early Steps
           Providers will be required to submit data for ALL services provided to Part C families. This
           includes Medicaid, private insurance and other third party funded services.

       2   The service data provided to the H.P.C. by the Provider will not only be entered into the State of
           Florida’s Early Steps Data System, but also will be used as the documentation for
           billing/invoicing the State of Florida’s Early Steps Program.

       3. The invoice and IAR form will constitute the request for payment. The Early Steps of SWFL
          fiscal billing report will be the report which lists the specific services provided by the agency,
          which are funded with Early Steps of SWFL funds. Reports for services funded by other payers
          will be available upon request.

       4. Upon inspection and approval of a properly prepared invoice received within the proper time
          frame, the HPC will process said invoice for payment.

       5. Payment will be made within forty-five (45) days of filing appropriate reimbursable services.

C.     HPC. reserves the right to determine if or when Part C funds may be used in emergency situations or
       when determination of payment responsibility has not been made and a service must be provided
       prior to such a determination. In such cases, the H.P.C. agrees to so inform the Provider.

III. THE PROVIDER AND HEALTH PLANNING COUNCIL OF SOUTHWEST FLORIDA, INC.
       MUTUALLY AGREE:
     A. Effective Date:
        This subcontract shall begin on July 1, 2010 and will terminate on June 30, 2011 as long as the
        Provider abides by the guidelines of this agreement, unless otherwise terminated as provided
        herein, and funding is available.

     B. Contractual Relationship:
        The relationship of the parties shall be an independent contractor relationship and not an agency,
        employment, joint venture, or partnership relationship. Neither party shall have the power to bind
        the other party or contract in the name of the other party. All persons employed by a party in
        connection with operations under this contract shall be considered employees of that party and
        shall in no way, neither directly nor indirectly be considered employees of the other party.

     C. Termination:
       1. Termination at will: This subcontract may be terminated by either party upon no less than
          thirty (30) calendar days’ notice, without cause, unless a shorter time is mutually agreed upon by
          both parties. Said notice shall be delivered by certified mail, return receipt requested or in
          person, with proof of delivery.

       2. Termination due to lack of funds: In the event that funds to finance this subcontract become
          unavailable, the H.P.C. may terminate the subcontract upon no less than twenty-four (24) hours
          notice in writing to the provider. Said notice shall be delivered by certified mail, return receipt

The Health Planning Council of Southwest Florida, Inc.                          Provider Contract 2010-2011
                    EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                         FY 2010-2011
                                        Page 8 of 13

          requested, or in person, with proof of delivery. The H.P.C. shall be the final authority as to the
             availability of funds.

          3. Termination for breach: Unless the Provider’s breach is waived by the H.P.C. in writing, the
             H.P.C. may, by written notice to the Provider, terminate this subcontract after no less than
             twenty-four (24) hours notice. Said notice shall be delivered by certified mail, return receipt
             requested or in person, with proof of delivery. Waiver of breach of any provision of this
             subcontract shall not be deemed to be a waiver of any other breach and shall not be construed to
             be a modification of the terms of this subcontract.

          4. The provisions of this subparagraph do not limit the H.P.C.’s right to remedies at law or to
             damage.

D.          Notice and Contact
          1. The name, address, and telephone number of the Health Planning Council of Southwest Florida,
             Inc. for the purposes of this subcontract is:

                          Dr. Edward Houck - President
                          The Health Planning Council of Southwest Florida, Inc
                          8961 Daniels Center Drive, Suite #401
                          Fort Myers, Florida 33912
                          (239) 433-6700

          2. The name, telephone number and e-mail address of the representative of the Provider
             responsible for administration of the program under this subcontract and the official Agency
             address for the Provider is:

                          «Firstname» «Lastname»
                          «Agency Address1»
                          «Agency City», «Agency State_Agency Zip_Code»
                          «HomePhone»         «Email_Address»
                          Cell Phone:

          3. In the event that different representatives are designated by either party after the execution of
             this subcontract, notice of the name of the new representative will be rendered in writing to the
             other part and official Agency address, and said Notification attached to the originals of this
             subcontract.

     E. Payment of Authorized Service:
        This subcontract does not obligate the H.P.C. to pay the Provider unless the services rendered
        were previously authorized on the current Individualized Family Support Plan.

     F.    Indemnification:
           Provider, its’ assignees, agents, or subcontractors, agrees to indemnify and hold the H.P.C., its’
           assignees, agents, or subcontractors, harmless from all claims, liabilities, damages, losses, and
           expenses, including attorney’s fees and court costs, asserted by a third party for negligent acts or

The Health Planning Council of Southwest Florida, Inc.                              Provider Contract 2010-2011
                   EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                        FY 2010-2011
                                       Page 9 of 13

        omission committed by Provider, its’ assignees, agents, or subcontractors, during the term of this
        agreement. The terms of this paragraph shall survive any termination of this agreement.

   G. Renegotiation or Modification:

        This agreement and any attachments represent the entire agreement between the parties hereto.
        Modification of the provisions of this agreement shall be valid only when they have been reduced
        to writing and duly signed by both Provider and the H.P.C.

        The Provider is to be made aware that the agreement will be amended to incorporate the
        provisions of a sliding fee schedule and/or a family financial participation mechanism in
        compliance with the State of Florida Part C Federal Grant Application and the proviso language in
        the Appropriations Act, at such time as the State of Florida Children’s Medical Services (CMS)
        Program office develops procedures for such a mechanism.

   H. Venue:
      This agreement shall be construed under the laws of the State of Florida and any action brought to
      enforce the terms of this agreement shall be brought in the appropriate Court in Lee County,
      Florida.

   I.   Name, Address of Payee:
        The name (Provider names as shown on page one of this subcontract) and mailing address of the
        official payee to whom payment shall be made is:

                          «Business»
                          «Firstname» «Lastname»
                          «Address1»
                          «City», «State_Zip_Code»

IV. ALL TERMS AND CONDITIONS INCLUDED:
    This Subcontract and the attachments referenced, Attachments I through VII, the State of Florida
    Department of Health Contract, contain all the terms and conditions agreed upon by the parties.




The Health Planning Council of Southwest Florida, Inc.                         Provider Contract 2010-2011
                   EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                        FY 2010-2011

                                                    Page 10 of 13



IN WITNESS WHEREOF, the parties have caused this contract to be executed by their undersigned
officials, as duly authorized.

PROVIDER: «Business»                                       The Health Planning Council of SW Florida, Inc.
                                                           Early Steps of Southwest Florida’s Program

____________________________________
«Firstname» «Lastname»«Next Record»                         Edward W. Houck, President
                                                            The Health Planning Council of Southwest Florida, Inc.


DATE                                                        DATE

____________________________________
WITNESSED BY:                                 DATE          WITNESSED BY:                                   DATE


WITNESSED BY: (Please print)                                WITNESSED BY (Please print)



WITNESSED BY:                                               WITNESSED BY:


WITNESSED BY: (Please print)                                WITNESSED BY (Please print)

                                                            59-2269305
Tax ID Number/Social Security Number                        Federal ID Number




The Health Planning Council of Southwest Florida, Inc.                                Provider Contract 2010-2011
                    EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                         FY 2010-2011
                                         Page 11 of 13

                                     PROVIDER CONTRACT ADDENDUM

I.     Requirements of Team Members and Providers providing services in Natural Environments
       Physical:

     A. Ability to lift up to fifty (50) pounds. Ability to carry a case weighing up to twenty (20) pounds.

     B. Ability to bend, stoop to child’s level, and, if necessary crawl and sit on the floor.

     C. Ability to climb up to two flights of stairs.

     D. Retain a valid State of Florida motor vehicle operator license; maintain valid automotive insurance
        and vehicle registration issued by the State of Florida Department of Transportation.

     E. Successful completion of a Level II Background Check

     F. Maintain a postal mailing, fax machine and an e-mail address for receipt and submittal of office
        files, billing, reports and other information. Computer software minimal requirements include the
        ability to receive and read Microsoft Word, Excel and e-mail file attachments in Acrobat Reader.
        Providers will maintain active software for protection from computer viruses capable of receiving
        continual updates. E-mail and all computer files must be password protected. Federal HIPAA
        regulations prohibit use of e-mail to transmit client information unless it is encrypted. All faxed
        information must include a cover sheet with a HIPAA compliant confidentiality statement.

     G. Obtain a cellular phone capable of sending and receiving calls in all four (4) counties.

     H. Obtain an opaque box or briefcase with lock. Confidential information will either be hand carried or
        kept locked in the box/briefcase in the trunk of the car during assessments and services.

     I. Provide notice to Early Steps of SWFL of vacation or other time off in excess of two (2) weeks at
        least one (1) month in advance.

     J. Maintain a personal fax machine available for receiving incoming faxes twenty-four (24) hours per
        day. Fax machine must be located in a secure area of agency or home.


 II.    Requirements of All Contractors Not Paid Under The Health Planning Council of Southwest
        Florida’s Inc. Employee Payroll System
       A. A United States Internal Revenue Service Form W-9 (Request for Taxpayer Identification
          Number and Certification)

       B. Proof of enrollment and approval as a provider by the State Provider Enrollment Office

       C. Attendance at Team Assessments, Team Reviews, Transitions and other Team meetings




 The Health Planning Council of Southwest Florida, Inc.                              Provider Contract 2010-2011
                   EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                        FY 2010-2011
                                        Page 12 of 13

    D. Provider agencies will procure and maintain, throughout the period of this Contract,
       Comprehensive General Liability Insurance as required by the State of Florida Department of
       Health’s Contract.

    E. Submit and maintain Individual Professional Liability Insurance

The Provider will have thirty (30) days from signing the Contract to obtain and submit proof of
ability to meet all requirements. Failure to meet requirements within the thirty (30) day deadline
may result in requiring the provider to cease providing services until the requirements have been
met.


III. Disciplinary Policy
     The following actions may result in disciplinary action, and may result in immediate termination of
     this contract and dis-enrollment from the Part C Provider Network.
     Dishonesty

       Willful falsification of any documents including, but not limited to, enrollment documents,
        training documents, invoices, mileage logs, children’s records.

       Any intimidating or threatening behavior targeted towards children and/or families or Early Steps
        of SWFL employees, staff or any other provider or professional.

       Failure to maintain confidentiality concerning children and families


IV. Service Certifications
    Provider will submit with this Contract a check list of services Provider can perform for Early Steps
    of SWFL (Attachment I). This list will serve as the basis for Team Assignments. It will be the
    responsibility of the Provider to submit and maintain all documents certifying provider credentials.
    Early Steps of SWFL will submit a list of missing documentation. The Provider will have thirty-
    (30) days to submit deficient or missing information and produce evidence of proper credentialing.
    If information is not submitted within thirty- (30)-days, the Provider may have to cease providing
    services until information is submitted and approved by Early Steps of SWFL.

    A. Early Steps of SWFL’s Referral Packet must be returned to Early Steps of SWFL within five (5)-
       business days for inability to provide services.

     B. Provider will inform Early Steps of SWFL immediately upon change in family’s third party
        insurance including Medicaid.
     C. Provider will inform Early Steps of SWFL immediately of a change in service personnel,
        termination of service personnel or of a leave of absence of service personnel of longer than two
        (2) weeks.




The Health Planning Council of Southwest Florida, Inc.                         Provider Contract 2010-2011
                     EARLY STEPS of SWFL COMMUNITY PROVIDER CONTRACT
                                          FY 2010-2011
                                         Page 13 of 13.

     D. Provider will offer family service coverage options if Provider is away or closed for more than two
        (2) weeks. If no options exist, Provider will seek coverage from the Team Service Coordinator.

     E. Provider will document missed sessions and reasons for missed sessions on the Monthly
        Team Status Report to Early Steps of SWFL and submit no later than with the month’s
        billing invoice on the 15th of the next month.

     F. Provider will notify families in advance if services are not available. Providers under no
        circumstances will maintain a waiting list for Part C children and families.

     G. Provider will begin services within 30 days of IFSP authorization date. The Provider referral
        checklist (attachment III-h) will be returned with the first invoice following initiation of services.
        The initial date of service and contact attempts must be documented on the form.

     H. Providers cannot be guaranteed specific numbers or locations for referrals or service delivery
        hours.


V.          List of Enclosed Attachments


     I.          Provider Check List

     II.         Early Steps Summary of Family Rights.

     III.        Billing Forms
            a.       Monthly Provider Invoice and Fee Schedule
            b.       Natural Environment Travel Log
            c.       Monthly Provider Team Status Report
            d.       IAR Form
            e.       PSP Update HELP Report for Team Review
            f.       Participation in IFSP Meeting Documentation
            g.       Consultation Among Service Provider Team Members
            h.       Provider referral checklist
            i.       Quality Assurance checklist on-site visit record.




The Health Planning Council of Southwest Florida, Inc.                            Provider Contract 2010-2011

				
DOCUMENT INFO