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<br />270 (Form GC-lO), is due no later than ninety (90) days after the end of the Attachment <br />term. This report shall be marked "Final". <br /> <br />PERFORMING AGENCY shall notify RECEIVING AGENCY immediately in the event <br />of any significant change affecting the PERFORMING AGENCY'S identity, ownership <br />or control, name change, governing board membership, vendor identification, medical or <br />program director, changes in hours of operation, clinic site information regarding closure, <br />relocation, change of address, and openings of new clinic sites. Failure to disclose the <br />required information or inaccurate disclosure by the PERFORMING AGENCY may be <br />treated as a material breach of this contract and may be grounds for termination. <br /> <br />BILLING REOUIREMENTS <br /> <br />PERFORMING AGENCY shall bill RECEIVING AGENCY on a monthly basis for <br />allowable services provided to Title V eligible clients. Bills for all allowable services <br />shall be submitted as aggregate activity reports with a DSHS Monthly Reimbursement <br />Request and shall not refer to or identify individual clients. PERFORMING AGENCY <br />shall bill within thirty (30) days after the end of the month which services were provided <br />or within sixty (60) days in cases of potentially Medicaid eligible individuals who are <br />denied eligibility by the Health and Human Services Commission. All bills shall be <br />submitted within ninety (90) days of the end of the Attachment term. <br /> <br />In billing RECEIVING AGENCY, PERFORMING AGENCY shall certify that all billed <br />services have been provided only to individuals who have been determined to be eligible <br />for Title V services. RECEIVING AGENCY will pay PERFORMING AGENCY for all <br />acceptable vouchers submitted up to PERFORMING AGENCY'S contract ceiling <br />amount. Billing vouchers submitted outside of the time frames indicated above shall be <br />subj ect to disallowance. <br /> <br />BILLING ACTIVITY <br /> <br />RECEIVING AGENCY shall distribute funds in a way that will maximize the delivery of <br />authorized services to eligible clients. RECEIVING AGENCY will monitor <br />PERFORMING AGENCY'S billing activity. If utilization is below that projected in <br />PERFORMING AGENCY'S contract ceiling amount, shown in SECTION III. BUDGET, <br />PERFORMING AGENCY'S ceiling may be subject to a decrease for the remainder of the <br />contract Attachment period. PERFORMING AGENCY may be subject to contract <br />ceiling amount decreases if PERFORMING AGENCY'S billing activity is less than <br />projected. <br /> <br />RECEIVING AGENCY may pay for additional services as specified in this Attachment <br />if provided by PERFORMING AGENCY during the term of this Attachment (but not <br />otherwise paid during the term of this Attachment) if is in the best interest of the State <br />and the RECEIVING AGENCY Program to do so, and funds are available. If <br />PERFORMING AGENCY exceeds the ceiling amount of the Attachment, <br />PERFORMING AGENCY shall continue to bill RECEIVING AGENCY for the services <br />provided. RECEIVING AGENCY may pay for these additional services if funds become <br />available at a later date. <br /> <br />ATTACHMENT - Page 3 <br />