2006-108-RES-DSHS Document NO. 2007-020428, Regional and Local Medical Services

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· Other data and/or reports as deemed necessary by DSHS, upon reasonable notice to Contractor. Contractor shall submit the PHC 200 with the Monthly Reimbursement Request (MRR) within 30 days following the end ofthe prior month. Contractor shall submit the PHC 301 within 30 days after the end of each quarter. DSHS requires comprehensive reports to assess the volume and quality of services being provided. Contractor shall submit the PHC 300 within 90 days of the end of the Attachment term to the Performance Management Unit, Contract Management Branch. Failure to submit reports in a timely manner may result in sanctions according to provisions of the contract. General Provisions, Compliance and Reporting Article, Section 1.05 is revised to include: Eligibility: All individuals considered for PHC eligibility must be screened and determined eligible using a DSHS or PHC program-approved screening process as updated in the spring of each year when federal poverty levels and eligibility determination forms are revised. General Provisions, Services Article, Section 2.05, is revised to include: Contractor may assess a co-pay from clients who receive services under this contract Attachment. A co-pay assessment may not exceed 25% of the amount DSHS pays Contractor for the provision of a given service. A client shall not be denied services due to inability to pay. Contractor shall make reasonable efforts to investigate and apply for all other sources ofthird party funding available to, or identified by, the patient before submitting DSHS Program claims for allowable costs. General Provisions, Terms and Conditions of Payment Article, Section 5.04 is replaced with the following: Contractor shall accept reimbursement or payment from DSHS and any applicable fees from clients for clinical health services as payment in full for services or goods provided to clients. Contractor agrees to not seek additional reimbursement or payment for services or goods from clients other than applicable fees for clinical health services. General Provisions, Access and Inspection Article, Section 9.01 is revised to include: Contractor shall allow DSHS to conduct on-site quality assurance reviews as deemed necessary by DSHS. Unsatisfactory review fmdings may result in implementation of General Provisions, Breach of Contract and Remedies for Non-Compliance Article. General Provisions, General Business Operations of Contractor Article, Section 12.19, is revised ATTACHMENT -Page 3