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- "Medi-Cal Ground Emergency Medical Transportation Services (Gemt) Supplemental Reimbursement Program Provider Participation Agreement Form" - California
"Medi-Cal Ground Emergency Medical Transportation Services (Gemt) Supplemental Reimbursement Program Provider Participation Agreement Form" - California
Medi-Cal Ground Emergency Medical Transportation Services (Gemt) Supplemental Reimbursement Program Provider Participation Agreement Form is a legal document that was released by the California Department of Health Care Services - a government authority operating within California.
Form Details:
- The latest edition currently provided by the California Department of Health Care Services;
- Ready to use and print;
- Easy to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.
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11MEDI-CAL GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES (GEMT)
SUPPLEMENTAL REIMBURSEMENT PROGRAM
PROVIDER PARTICIPATION AGREEMENT
National Provider ID #
Name of Provider:
ARTICLE 1 – STATEMENT OF INTENT
The purpose of this Agreement is to allow participation in the Ground Emergency Medical
Transportation Supplemental Reimbursement Program (GEMT program) by the
governmentally owned or operated provider, named above and hereinafter referred to as
Provider, subject to Provider’s compliance with the responsibilities set forth in this
Agreement with the California Department of Health Care Services (DHCS), hereinafter
referred to as the State or DHCS, as authorized in State law pursuant to section 14105.94
of the California Welfare and Institutions Code.
ARTICLE 2 – TERM OF AGREEMENT
A. This Agreement begins on January 30, 2010, and stays in effect until this Agreement is
terminated or the GEMT program ends pursuant to the repeal of State or federal
statutory authority to make payments or claim federal reimbursement.
B. Either party may terminate this Agreement, without cause, by delivering written notice
of termination to the other party at least thirty (30) days prior to the effective date of
termination.
C. Failure by Provider to comply with Provider’s responsibilities under Article 3 shall
constitute a material breach of this Agreement, which shall result in termination by
Provider pursuant to Paragraph B.
Provider may prevent the termination of this
Agreement pursuant to this Paragraph by curing any material breach prior to
termination of this Agreement, unless actions giving rise to the material breach result
from not complying with Paragraphs K, L, M, or N of Article 3.
D. Failure by Provider to comply with Provider’s responsibilities under Paragraph O of
Article 3 shall result in an immediate suspension of this Agreement and initiate
termination pursuant to Paragraph B.
Upon suspension, the Provider may not
participate in the GEMT program, Provider’s claims identified in Article 4 shall not be
reimbursed, and DHCS is no longer subject to its obligations in Article 4. Provider may
reverse the suspension and prevent termination by complying with Paragraph O of
Article 3 in its entirety.
Page 1 of 11
MEDI-CAL GROUND EMERGENCY MEDICAL TRANSPORTATION SERVICES (GEMT)
SUPPLEMENTAL REIMBURSEMENT PROGRAM
PROVIDER PARTICIPATION AGREEMENT
National Provider ID #
Name of Provider:
ARTICLE 1 – STATEMENT OF INTENT
The purpose of this Agreement is to allow participation in the Ground Emergency Medical
Transportation Supplemental Reimbursement Program (GEMT program) by the
governmentally owned or operated provider, named above and hereinafter referred to as
Provider, subject to Provider’s compliance with the responsibilities set forth in this
Agreement with the California Department of Health Care Services (DHCS), hereinafter
referred to as the State or DHCS, as authorized in State law pursuant to section 14105.94
of the California Welfare and Institutions Code.
ARTICLE 2 – TERM OF AGREEMENT
A. This Agreement begins on January 30, 2010, and stays in effect until this Agreement is
terminated or the GEMT program ends pursuant to the repeal of State or federal
statutory authority to make payments or claim federal reimbursement.
B. Either party may terminate this Agreement, without cause, by delivering written notice
of termination to the other party at least thirty (30) days prior to the effective date of
termination.
C. Failure by Provider to comply with Provider’s responsibilities under Article 3 shall
constitute a material breach of this Agreement, which shall result in termination by
Provider pursuant to Paragraph B.
Provider may prevent the termination of this
Agreement pursuant to this Paragraph by curing any material breach prior to
termination of this Agreement, unless actions giving rise to the material breach result
from not complying with Paragraphs K, L, M, or N of Article 3.
D. Failure by Provider to comply with Provider’s responsibilities under Paragraph O of
Article 3 shall result in an immediate suspension of this Agreement and initiate
termination pursuant to Paragraph B.
Upon suspension, the Provider may not
participate in the GEMT program, Provider’s claims identified in Article 4 shall not be
reimbursed, and DHCS is no longer subject to its obligations in Article 4. Provider may
reverse the suspension and prevent termination by complying with Paragraph O of
Article 3 in its entirety.
Page 1 of 11
GEMT Provider Participation Agreement
ARTICLE 3 – GEMT PROVIDER RESPONSIBILTIES
By entering into this Agreement, the Provider agrees to:
A. Comply with Title XIX of the Social Security Act, as periodically amended; Titles 42 and
45 of the Code of Federal Regulations (CFR), as periodically amended; The California
Medicaid State Plan, as periodically amended; Chapter 7 (commencing with Section
14000) of the California Welfare and Institutions (W&I) Code, as periodically amended;
Division 3 of Title 22 of the California Code of Regulations (CCR) (commencing with
Section 50000), as periodically amended; State issued policy directives, including
Policy and Procedure Letters, as periodically amended; and federal Office of
Management
and
Budget
(OMB)
Circular
A-87,
as
periodically
amended.
B. Ensure all applicable State and federal requirements, as identified in Paragraph A of
Article 3, are met in rendering services under this Agreement. It is understood and
agreed that failure by the Provider to ensure all applicable State and federal
requirements are met in rendering services subject to supplemental reimbursement
under this Agreement shall be sufficient cause for the State to deny or recoup
payments to the Provider as well as termination of this Agreement.
C. Submit an annual participation survey to DHCS by July 1 of each state fiscal year
to:
Regular U.S. Postal Service Mail:
Overnight or Express Mail:
Department of Health Care Services
Department of Health Care Services
Safety Net Financing, GEMT Program
Safety Net Financing, GEMT Program
P.O. Box 997436, MS 4504
1501 Capitol Ave, MS 4504
Sacramento, CA 95899-7436
Sacramento, CA 95814
D. Comply with the following Expense Allowability and Fiscal Documentation
requirements:
1) Provider cost report and claim form that are accepted or submitted for payment by
the State shall not be deemed evidence of allowable Agreement costs.
2) Provider shall maintain for review and audit and supply to the State, upon request,
auditable documentation of all amounts claimed pursuant to this Agreement to
permit a determination of expense allowability.
3) If the allowability or appropriateness of an expense cannot be determined by the
State because invoice detail, fiscal records, or backup documentation is nonexistent
or inadequate, according to generally accepted accounting principles or practices,
all questionable costs may be disallowed and payment may be withheld by the
State.
Upon receipt of adequate documentation supporting a disallowed or
questionable expense, reimbursement may resume for the amount substantiated
and deemed allowable.
Page 2 of 11
GEMT Provider Participation Agreement
E. By November 30 of each year:
1) Submit a signed electronic PDF copy of the annual GEMT Cost Report for the prior
fiscal year ending June 30, to:
GEMTSubmissions@dhcs.ca.gov
F. Accept payment in full the reimbursement received for services subject to supplemental
reimbursement pursuant to this Agreement.
G. Comply with confidentiality requirements as specified in paragraph (7) of subsection (a)
of section 1396a of Title 42 of the United States Code, 42 CFR 431.300, W&I Code
sections 14100.2 and 14132.47, and 22 CCR Section 51009.
H. Submit claims in accordance with 42 CFR 433.51.
I. Retain all necessary records for a minimum of three (3) years after the end of the
quarter in which the provider submitted its cost reports to DHCS. If an audit is in
progress, all records relevant to the audit shall be retained until the completion of the
audit or the final resolution of all audit exceptions, deferrals, and/or disallowances.
Records must fully disclose the name and Medi-Cal number or beneficiary identification
code (BIC) of the person receiving the services, the name of the provider agency and
person providing the service, the date and place of service delivery, and the nature and
extent of the service provided. The Provider shall furnish said records and any other
information regarding expenditures and revenues for providing services, upon request,
to the State and to the federal government.
J. Be responsible for the acts or omissions of its employees and/or subcontractors.
K. Comply with the following requirements pertaining to exclusions. The conviction of an
employee or subcontractor of the Provider, or of an employee of a subcontractor, of
any felony or of a misdemeanor involving fraud, abuse of any Medi-Cal beneficiary, or
abuse of the Medi-Cal program, shall result in the exclusion of that employee or
subcontractor, or employee of a subcontractor, from participation in the GEMT
Program. Failure to exclude a convicted individual from participation in the GEMT
Program shall constitute a breach of this Agreement.
L. Comply with the following requirements pertaining to exclusions.
Exclusion after
conviction shall result regardless of any subsequent order under section 1203.4 of the
Penal Code allowing a person to withdraw his or her plea of guilty and to enter a plea
of not guilty, or setting aside the verdict of guilty, or dismissing the accusation,
information, or indictment.
M. Comply with the following requirements pertaining to exclusions.
Suspension or
exclusion of an employee or a subcontractor, or of an employee of a subcontractor,
from participation in the Medi-Cal program, the Medicaid program, or the Medicare
program, shall result in the exclusion of that employee or subcontractor, or employee of
Page 3 of 11
GEMT Provider Participation Agreement
a subcontractor, from participation in the GEMT program.
Failure to exclude a
suspended or excluded individual from participation in the GEMT program shall
constitute a breach of this Agreement.
N. Comply with the following requirements pertaining to exclusions.
Revocation,
suspension, or restriction of the license, certificate, or registration of any employee,
subcontractor, or employee of a subcontractor, shall result in exclusion from the GEMT
program, when such license, certificate, or registration is required for the provision of
services. Failure to exclude an individual whose license, certificate, or registration has
been revoked, suspended, or restricted from the provision of services may constitute a
breach of this Agreement.
O. Enter into a separate agreement with a host entity in order to satisfy the requirements
in subdivision (d) of section 14105.94 of the W&I Code where the host entity will collect
the payments from Provider in order to pay DHCS for its administrative costs, which
are the costs incurred by DHCS pursuant to its responsibilities described in Article 4. If
Provider is the host entity, then it shall enter into a separate agreement with DHCS to
pay the administrative costs incurred in processing the claims of the GEMT program
invoiced through the separate agreement. If Provider is the host entity and contracts
with at least one other provider for purposes of participating in the GEMT program,
then it shall enter into an agreement with other such providers participating in the
GEMT program to collect payments from the other providers for DHCS’s administrative
costs incurred in processing the other provider’s claims under the GEMT program.
ARTICLE 4 – STATE RESPONSIBILITIES
By entering into this Agreement, the State agrees to:
A. Lead the development, implementation, and administration for the GEMT program and
ensure compliance with the provisions set forth in the California Medicaid State Plan.
B. Submit claims for federal financial participation (FFP) based on expenditures for GEMT
services that are allowable expenditures under federal law.
C. On an annual basis, submit any necessary materials to the federal government to
provide assurances that claims for FFP will include only those expenditures that are
allowable under federal law.
D. Reconcile
certified
public
expenditure
(CPE)
invoices
with
supplemental
reimbursement payments and ensure that the total Medi-Cal reimbursement provided
to eligible GEMT providers will not exceed applicable federal upper payment limit as
described in 42 C.F.R. 447-Payments For Services.
Page 4 of 11
GEMT Provider Participation Agreement
E. Complete the audit and settlement process of the interim reconciliations for the
claiming period within three (3) years of the postmark date of the cost report and
conduct on-site audits as necessary.
F. Calculate the actual costs for administrative accounting, policy development, and data
processing maintenance activities, including the indirect costs related to the GEMT
program provided by its staff based upon a cost accounting system which is in
accordance with the provisions of Office of Management and Budget Circular A-87 and
45 CFR Parts 74 and 95.
G. Maintain accounting records to a level of detail which identifies the actual expenditures
incurred for personnel services which includes salary/wages, benefits, travel and
overhead costs for Contractor’s staff, as well as equipment and all related operating
expenses applicable to these positions to include, but not limited to, general expense,
rent and supplies, and travel cost for identified staff and managerial staff working
specifically on activities or assignments directly related to the GEMT program.
Accounting records shall include continuous time logs for identified staff that record
time spent in the following areas: the GEMT program, general administration.
H. Ensure that an appropriate audit trail exists within Contractor records and accounting
system and maintain expenditure data as indicated in this Agreement.
I. Designate a person to act as liaison with Provider in regard to issues concerning this
Agreement.
This person shall be identified to Provider’s contact person for this
Agreement.
J. Provide a written response by email or mail to Provider’s contact person within thirty
(30) days of receiving a written request for information related to the GEMT program.
K. Provide program technical assistance and training related to the GEMT program to
Provider personnel after receiving a written request from Provider contact person.
ARTICLE 5 –PROJECT REPRESENTATIVES
A. The project representatives during the term of this Agreement will be:
Department of Health Care Services Name:
Prov
ider
Shiela Mendiola
Nam
e:
Unit: Medi-Cal Supplemental Payment Section
Telep
hone:
Telephone: (916) 552-9615
Fax:
Fax: (916) 552-8651
Ema
il:
Email: GEMT@dhcs.ca.gov
Page 5 of 11
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