AMD RE 3RD PARTY REIIMB ORAL HLTH WITH ADHS.PDF

C-86-16-080-3-04
ADHS16-123017
AMENDMENT 3 TO INTERGOVERNMENTAL AGREEMENT
Between
MARICOPA COUNTY By and Through it's
DEPARTMENT OF PUBLIC HEALTH, Office of Oral Health,
And
Arizona Department of Health Services
for
Third Party Reimbursement for Fluoride Varnish Services
I. The above named contract is hereby amended for Year Three (3) as specified below:
5. Start Date: July 1, 2017
6. Expiration Date: June 30, 2018
Section III
4. Tasks
K. Provide Maricopa County Office of Oral Health (MCOOH) First Teeth First (FTF) program
with annual revenue reports that represent all claims reimbursed for that year no later
than 30 days following the month at the close of the fiscal year to include:
1. Date payment was received, Check Date, Check Number, Organization or Health
Plan making the payment, Payment Amount, Deposit Date and DOC Number
2. MCOOH FTF reserves the right to request a review of ADHS 00H expense tracking
procedures, reimbursements and funds distribution process for quality assurance
purposes.
L. Distribute revenue funds to MCOOH FTF from claims in excess of $216,528 that are
generated from July 1, 2015 thru June 30, 2018 based on the following:
1. Generated revenue for MCDPH is estimated not to exceed $500,000.00 for the
Budget Period July 1, 2015 through June 30, 2018.
2, Revenue distribution will be submitted no later than 30 days following the close of a
quarter,
3. Any distribution of funds made to MCOOH FTF program will only be submitted after
the expense of the billing service by ADHS OOH has been received.
All other terms and conditions of the original contract and amendments shall remain in full
force and effect.
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C-86-16-080-3-04
ADHS16-123017
IN WITNESS WHEREOF, the parties agree to the changes indicated herein:
FOR AND ON BEHALF OF FOR AND ON BEHALF OF
IV1ARICOPA COUNTY Arizona Department of Health Services
By:
Denny Barney
Chairman, Board of Supervisors
7/0 7
Date Date
ATTEST ATTEST
Clerk of the Board
Date Date
APPROVED AS TO FORM APPROVED AS TO FORM
Attorney for Maricopa County
7- 5 -1-7
Date Date
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