2007-116-RES-Approving and Authorizing the Execution of a Contract with the Department of State Health Services (DSHS) Document No. 2008-024100

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Contractor shall make reasonable efforts to investigate and apply for all other sources of third party funding available to, or identified by, the patient before submitting DSHS Program claims for allowable costs. General Provisions, Services Article, is revised to include: Pharmacy: If Contractor is dispensing and/or providing prescription medications, e.g., birth control pills, antibiotics, etc., on site, it shall have, at a minimum, a Class D pharmacy license as provided by the Texas Pharmacy Act, Occupations Code, Chapter 560, or shall dispense and/or provide such medications in compliance with other pharmacy statutes with prior approval from DSHS. General Provisions, Funding Article, Section 3.05, is revised to include: Program Income maybe collected and retained by Contractor so long as it is used to provide services specified in the scope of work detailed in this contract Attachment. The use of Program Income shall be reported on the monthly billing vouchers for services provided to Title V eligible clients. General Provisions, Payment Methods and Restrictions Article, Section 4.02, is revised to include: Contractor's contract amount under this contract Attachment is a ceiling against which it may bill, on afee-for-service basis, for the provision of allowable services to Title V eligible clients. Only allowable services provided to Title V eligible clients may be billed against this ceiling. The current schedule of allowable services and rates, as well as Title V eligibility requirements, may be modified at the sole discretion of DSHS with thirty (30) days written notice to Contractor. The notice will provide Contractor with an opportunity to terminate this contract Attachment should the modification include a reduction in rates. Contractor shall have thirty (30) days from receipt of this notice to exercise the option for termination. If the Contractor does not exercise the option during the thirty (30) day time period, Contractor shall be deemed to have waived the option. A Request for "Advance or Reimbursement", Form 270 (Form GC-10), or the form specified in the Contractor's Financial Procedures Manual, is due no later than sixty (60) days after the end of the contract Attachment term. This report shall be marked "Final". Billing Requirements: Contractor shall bill DSHS on a monthly basis for allowable services provided to Title V eligible clients. Bills for all allowable services shall be submitted as aggregate activity reports with a DSHS Monthly Reimbursement Request and shall not refer to or identify individual clients. Contractor shall bill within thirty (30) days after the end of the month in which services were provided or within sixty (60) days incases of potentially Medicaid eligible individuals who are denied eligibility by the Health and Human Services PROGRAM ATTACHMENT -Page 4