Form SFN1296 "Contract to Provide Primary Care Case Management Services" - North Dakota

What Is Form SFN1296?

This is a legal form that was released by the North Dakota Department of Labor and Human Rights - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2016;
  • The latest edition provided by the North Dakota Department of Labor and Human Rights;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFN1296 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Labor and Human Rights.

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Download Form SFN1296 "Contract to Provide Primary Care Case Management Services" - North Dakota

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CONTRACT TO PROVIDE PRIMARY CARE CASE MANAGEMENT SERVICES
NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES
MEDICAL SERVICES DIVISION
Clear Fields
SFN 1296 (11-2016)
Provider Name
North Dakota Provider ID Number
National Provider Identifier (NPI) Number
This agreement is entered into between the North Dakota Department of Human Services, Medical Services Division (NDDHS),
hereinafter referred to as the Department, and the above named provider, hereinafter referred to as a Primary Care Provider
(PCP), whose primary care place of practice address/location is:
Address
City
State
ZIP Code
Telephone Number
Fax Number
Section I. General Statement of Purpose and Legal Authority
The purpose of this agreement is to obtain Primary Care Case Management (PCCM) services for designated recipients
participating in the North Dakota Medicaid program through appropriate referrals and authorizations of certain Medicaid services
for recipients who may select, or be assigned to, the contracting providers. The goal of the PCCM program is to increase
access to primary care, provide coordination and continuity of health care services, as well as minimize or reduce unnecessary
or inappropriate utilization of health care services. The PCP receives a per member per month (PMPM) management fee (for a
certain enrolled group of eligible Medicaid recipients) in exchange for the delivery of medically necessary primary care medical
services, referrals for specialty services, care coordination, and assistance with accessing the health care system.
A PCP may be an individual physician or Advanced Registered Nurse Practitioner (General Practice, Family Practice, Internal
Medicine, Pediatrics, or OB/GYN), a Federally Qualified Health Care Center (FQHC), a Rural Health Clinic (RHC), or Indian
Health Services (IHS).
This agreement describes the terms and conditions under which the agreement is made and the responsibilities of the parties
thereto. This agreement shall be construed as supplementary to the usual provider agreement entered into by providers
participating in the Medicaid Program, and all provisions of that agreement shall remain in full force and effect, except to the
extent they are superseded by the specific terms of this agreement. The provider agrees to abide by all existing laws,
regulations, rules and procedures applicable to the North Dakota Medicaid Primary Care Case Management program and North
Dakota Medicaid participation.
Term: This contract shall become effective upon signature of both parties and shall remain in effect until otherwise amended or
terminated pursuant to the terms of this contract. Renegotiations will not be addressed.
Section II. Enrollment, Disenrollment and Reenrollment of Recipients
1. Enrollments and re-enrollments shall occur at the county social services office as follows:
a.
Medicaid recipients eligible for the PCCM program (potential enrollees) will be sent information regarding the managed
health care options available within their local area and will be allowed to choose between them.
b.
If the recipient fails to make a selection of a managed health care option, a default enrollment selection will be made by
the Department. This selection is based on the recipients prior PCP assignment; household provider usage if appropriate;
provider specialty and an equitable distribution between providers available within the recipients local area.
An enrollee who loses North Dakota Medicaid eligibility for a period of 60 days or less will be automatically re-enrolled
c.
with the last provider chosen or assigned.
2. Recipients may choose a PCP among participating PCPs in their health care deliver area taking into consideration reaching
the providers delivery site within a reasonable time using available and affordable modes of transportation.
a. Recipients shall be permitted to change PCPs within the guidelines set forth by the Department by submitting either an
oral or written request to their local county social services office. The guidelines are as follows:
Enrollees may request a change in PCP any time during the first ninety days upon selecting a PCP,
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Every six months during open enrollment,
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Or for good cause. When a good cause request is made to change the PCP, the county eligibility worker must
determine if good cause exists and document the reasons and decision. Good cause reasons include, but are not
limited to: the Provider terminates his/her participation in the PCCM program; the enrollee has moved out of the
CONTRACT TO PROVIDE PRIMARY CARE CASE MANAGEMENT SERVICES
NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES
MEDICAL SERVICES DIVISION
Clear Fields
SFN 1296 (11-2016)
Provider Name
North Dakota Provider ID Number
National Provider Identifier (NPI) Number
This agreement is entered into between the North Dakota Department of Human Services, Medical Services Division (NDDHS),
hereinafter referred to as the Department, and the above named provider, hereinafter referred to as a Primary Care Provider
(PCP), whose primary care place of practice address/location is:
Address
City
State
ZIP Code
Telephone Number
Fax Number
Section I. General Statement of Purpose and Legal Authority
The purpose of this agreement is to obtain Primary Care Case Management (PCCM) services for designated recipients
participating in the North Dakota Medicaid program through appropriate referrals and authorizations of certain Medicaid services
for recipients who may select, or be assigned to, the contracting providers. The goal of the PCCM program is to increase
access to primary care, provide coordination and continuity of health care services, as well as minimize or reduce unnecessary
or inappropriate utilization of health care services. The PCP receives a per member per month (PMPM) management fee (for a
certain enrolled group of eligible Medicaid recipients) in exchange for the delivery of medically necessary primary care medical
services, referrals for specialty services, care coordination, and assistance with accessing the health care system.
A PCP may be an individual physician or Advanced Registered Nurse Practitioner (General Practice, Family Practice, Internal
Medicine, Pediatrics, or OB/GYN), a Federally Qualified Health Care Center (FQHC), a Rural Health Clinic (RHC), or Indian
Health Services (IHS).
This agreement describes the terms and conditions under which the agreement is made and the responsibilities of the parties
thereto. This agreement shall be construed as supplementary to the usual provider agreement entered into by providers
participating in the Medicaid Program, and all provisions of that agreement shall remain in full force and effect, except to the
extent they are superseded by the specific terms of this agreement. The provider agrees to abide by all existing laws,
regulations, rules and procedures applicable to the North Dakota Medicaid Primary Care Case Management program and North
Dakota Medicaid participation.
Term: This contract shall become effective upon signature of both parties and shall remain in effect until otherwise amended or
terminated pursuant to the terms of this contract. Renegotiations will not be addressed.
Section II. Enrollment, Disenrollment and Reenrollment of Recipients
1. Enrollments and re-enrollments shall occur at the county social services office as follows:
a.
Medicaid recipients eligible for the PCCM program (potential enrollees) will be sent information regarding the managed
health care options available within their local area and will be allowed to choose between them.
b.
If the recipient fails to make a selection of a managed health care option, a default enrollment selection will be made by
the Department. This selection is based on the recipients prior PCP assignment; household provider usage if appropriate;
provider specialty and an equitable distribution between providers available within the recipients local area.
An enrollee who loses North Dakota Medicaid eligibility for a period of 60 days or less will be automatically re-enrolled
c.
with the last provider chosen or assigned.
2. Recipients may choose a PCP among participating PCPs in their health care deliver area taking into consideration reaching
the providers delivery site within a reasonable time using available and affordable modes of transportation.
a. Recipients shall be permitted to change PCPs within the guidelines set forth by the Department by submitting either an
oral or written request to their local county social services office. The guidelines are as follows:
Enrollees may request a change in PCP any time during the first ninety days upon selecting a PCP,
l
l
Every six months during open enrollment,
l
Or for good cause. When a good cause request is made to change the PCP, the county eligibility worker must
determine if good cause exists and document the reasons and decision. Good cause reasons include, but are not
limited to: the Provider terminates his/her participation in the PCCM program; the enrollee has moved out of the
SFN 1296 (11-2016)
Page 2 of 6
provider's service area; the enrollee requires services not provided by the current PCP and lack of services would
subject the enrollee to unnecessary risk; quality of care concerns or lack of access to providers; or the member has
been enrolled in error. Voluntary disenrollment from a PCP is effective the day the request is received.
3. The PCP may disenroll or terminate the provider-patient relationship by providing 30 days written notice to the recipient and
to the Department. The reason for the termination must be considered “good cause” as outlined in the Managed Care
chapter of the General Information for Providers Manual. The reason(s) must be explained in writing, be non-discriminatory,
generally applied to the providers entire patient base, and approved by the Department. The PCP may not request
disenrollment due to a change in the enrollees health status or utilization of medical services, diminished mental capacity or
uncooperative behavior resulting from special needs, except when such behavior disrupts or seriously impairs the ability to
furnish services to this or to other enrollees.
Section III. Requirements to Provide Primary Care Case Management Services (General Terms and Conditions)
1. Must be a North Dakota Medicaid enrolled provider.
2.
Must comply with all applicable Federal and State laws and regulations.
Must agree to practice the provisions in, and sign the agreement for Participation as a Primary Care Provider (PCP) in the
3.
North Dakota PCCM program, which includes policy, information, and meeting the general requirements outlined in the
North Dakota Medicaid General Information for Providers Manual.
4.
Must accept enrollees, including voluntary and mandatory assignments, in the order in which they are enrolled.
Must treat enrollment as voluntary unless required by the Department.
5.
Must not discriminate on the basis of health status or need for health care services.
6.
7.
Must not discriminate against individuals enrolled on the basis of race, color, or national origin, and will not use any policy or
practice that has the effect of discriminating on the basis of race, color, or national origin.
8.
Must provide for arrangements with, or referrals to, sufficient numbers of physicians and other practitioners to ensure that
services under the contract can be furnished to enrollees promptly and without compromise to quality of care.
9.
Must transfer the enrollees medical record to the enrollees new PCP if requested in writing and authorized by the enrollee.
Must provide or arrange for suitable coverage for needed services, consultation, and approval of referrals during normal
10.
business hours including 24-hour availability of information, referral, and treatment for emergency medical conditions. This
includes coverage during vacations, illnesses and all other absences.
Must coordinate with the health management program including collaborating with the RN care managers within the ND
11.
Medicaid Health Management program, as requested.
Must not distribute any marketing material for the purpose of enrollment without first obtaining approval from the
12.
Department.
Must not conduct direct or indirect marketing activities specifically intended to influence recipients to enroll with the PCP or
13.
disenroll from another PCP.
14.
Must make available reasonable appointment availability based on routine, preventive, urgent, or emergent care needs.
15.
Must create and maintain a medical record for each enrollee that contains, at a minimum, the Medicaid identification number
of the patient, name, age, gender, address of the enrollee, documentation of services provided, where services were
provided and by whom, medical diagnosis, treatment, therapy, and medications prescribed or administered, all approvals for
covered services and referrals made to other providers for Medicaid services. Documentation should also include date of
referral, service, limits, procedures and other pertinent information if necessary to fulfill the need of the referring service. The
provider will document all authorizations for covered services provided by other providers. All medical records must comply
with federal requirements for utilization control (pursuant to 42 Code of Federal Regulations (CFR) 456).
16.
Must respond to requests from the Department for verification that specific services paid were actually authorized by the
PCP.
17.
Must notify the Department and/or the Department's Provider Enrollment area, (in writing) of any changes in practice (i.e.
no longer providing PCP services, change in specialty and/or location).
Section IV. Retention of Records
Financial records, supporting documents, statistical records, and all other pertinent records shall be retained for a period of three
years from the date of submission of the request for reimbursement. The only exceptions are the following: if any litigation,
claim, financial management review, or audit is started before the expiration of the three-year period, the records shall be
retained until all litigation, claims or audit findings involving the records have been resolved and final action taken; records for
real property and equipment acquired with federal funds shall be retained for three years after final disposition; when records are
transferred to or maintained by HHS awarding agency, the three-year retention requirement is not applicable to the recipient;
and indirect cost rate proposals, cost allocation plans, etc., as specified in 45 CFR 74.53(g).
SFN 1296 (11-2016)
Page 3 of 6
Section V. Responsibilities of NDDHS, Medical Services Division
1. Assign enrollees to a PCP as requested by the recipient or auto-assignment process.
2.
Provide enrollees and providers information regarding the PCCM program.
Provide the PCP with a list of enrollees each month. This list is generated at the end of the month for the current month
3.
served. (Some slight variance may occur from month to month).
4.
Pay each PCP a case management fee ($2.00) for each enrollee per month. The fee will be paid whether or not services
were delivered to an enrollee that month. FQHC, RHC, and IHS facilities are excluded from this payment.
Pay the contracted provider for medical services covered under the North Dakota Medicaid program provided to enrollees
5.
according to the fee-for-service reimbursement system in place in the North Dakota Medicaid program. For a current list of
covered services, refer to the General Information for Providers Manual.
6.
The Department may recoup case management fees/payments when it has determined through reliable evidence that an
overpayment has occurred. The amount to be recouped shall be equal to the amount of the overpayment. Recoupment
shall take place either through withholding future management fees or by way of direct billing to the PCP.
7.
The Department will establish a grievance procedure in order to resolve concerns of enrollees or providers relative to
services received or provided.).
Section VI. Emergency Services
Authorization of the PCP is not required for payment for services rendered in an emergency situation. Emergency services may
be performed regardless of location.
Section VII. Written Materials and Oral Interpretation Services
1.
The PCP will make available all written information regarding the practice in easily understood language and format as well
as in the prevalent non-English languages spoken in the practices service area.
2.
The PCP will provide oral interpretation services for any language at no cost to the enrollee or potential enrollee.
All written materials, including, but no limited to enrollment notices, informational materials and instructional materials must
3.
be provided to enrollees and potential enrollees in a manner and format that may be easily understood. Material must be
available in alternative formats and in an appropriate manner that takes into consideration the special needs of those who,
for example are visually limited or have limited reading proficiency. All enrollees must be informed that information is
available in alternative formats and how to access those formats.
Section VIII. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), also known as "Health Tracks"
1.
The Provider will render EPSDT services or make arrangements for EPSDT services to be provided to his/her eligible
members in accordance with the Health Tracks periodicity schedule.
2.
PCP authorization and referrals can be made to other providers and local health departments for EPSDT screening.
Section IX. Prohibitions
A PCP may not knowingly have a relationship with: (1) an individual who is debarred, suspended, or otherwise excluded from
participating in procurement activities under the Federal Acquisition Regulation or from participating in non-procurement
activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order No.
12549, or (2) an individual who is an affiliate of a person described above.
The relationships described in this paragraph include:
A director, officer, or partner of a PCP
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A person with beneficial ownership of five percent or more of the PCP's equity
A person with an employment, consulting or other arrangement with the PCP for the provision of items and services that is
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significant and material to the PCP's obligations under its contract with the Department
If the Department finds that a PCP is not in compliance with the above:
The Department must notify the Secretary of the noncompliance;
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May continue an existing agreement with the PCP unless the Secretary directs otherwise.
May not renew or otherwise extend the duration of an existing agreement with the PCP unless CMS provides to the State
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and to Congress a written statement describing compelling reasons that exist for renewing or extending the agreement.
SFN 1296 (11-2016)
Page 4 of 6
Section X. Sanctions
Sanctions are listed per the General Information for Providers-Medicaid and Other Medical Assistance Programs Manual,
Managed Care Chapter.
Section XI. Termination from Participation
1.
This agreement may be terminated by either party without cause upon giving the other party written notice 30 days in
advance of the desired date of termination or removal. The 30 days will allow enrollees time to select another PCP.
2.
The Department may terminate the agreement immediately upon written notice to the PCP when such termination is
considered to be in Medicaids best interest to assure the continuation of necessary and appropriate service to Medicaid
recipients.
Section XII. Legal Compliance
This contract must comply with all Federal and State laws and regulations, including title VI of the Civil Rights Act of 1964, title
IX of the Education Amendments of 1972 (regarding education programs and activities), the Age Discrimination Act of 1975, the
Rehabilitation Act of 1973, the Americans with Disabilities Act, the Byrd Anti-Lobbying Amendment and Equal Employment
Opportunity mandates. Additionally, no contract will be made to parties Excluded from Federal Procurement of non-
Procurement Programs.
The PCP agrees that federal funds have not and shall not be utilized for lobbying purposes.
Section XIII. Attachments
The following must be completed and signed to indicate the enrolling PCP understands the terms and conditions that regulate
the ND Medicaid PCCM Program:
Attachment A - Provider Enrollment Information
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Attachment B - Definitions
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I agree to comply with the participation requirements of a Primary Care Provider under the PCCM program, as cited in this
Agreement. I also agree that facsimiles of signatures shall constitute acceptable, binding signatures for purposes of this
Agreement. I certify that all information provided in this PCCM Contract is correct.
Primary Care Provider Signature
Date
Form Completed by:
Title
Date
STATE OFFICE USE ONLY
Medical Services Director or Designee
Date
Return form to:
ND Department of Human Services, Medical Services Division
600 E Boulevard Ave Dept 325
Bismarck ND 58505-0250
Email: dhsenrollment@nd.gov
Fax: (701) 328-1544
SFN 1296 (11-2016)
Page 5 of 6
Attachment A
Provider Enrollment Information
Practice Identification
PCP's Primary Care Practice
Physician
ARNP
RHC
FQHC
Indian Health Services (IHS)
PA-C
PCP's Specialty
Family / General Practice
Internal Medicine
Rural Health Clinic (RHC)
Obstetrics / Gynecology
Pediatrics
Indian Health Services (IHS)
Federally Qualified Health Center (FQHC)
PCP Site Name
Telephone Number
Address
City
State
ZIP Code
24-Hour Coverage Plan
After-Hours Telephone Number
After-Hours Access Will Be Handled By
An answering service contacts the site or a coverage provider after regular office hours
An answering machine directs patients to call a covering provider after regular office hours
Call forwarding transfers calls to another location where someone can contact the site or a covering provider after regular hours
Alternate Coverage Arrangements - Specify:
Office Hours and General Information About this Location
Monday
Tuesday
Wednesday
Thursday
AM
PM
AM
PM
AM
PM
AM
PM
Friday
Saturday
Sunday
AM
PM
AM
PM
AM
PM
Scheduling Information Not Listed Above
Page of 6