MARICOPA CO CHS GROUP BILLER AGREEMENT 11 30 16 FINAL.DOCX

GROUP BILLER PARTICIPATION AGREEMENT
Between
ARIZONA HEALTH CARE
COST CONTAINMENT SYSTEM ADMINISTRATION (“AHCCCSA”)
and
Maricopa County through Correctional Health Services 86-6000472
Group Biller Name SSN/Tax ID #
Located at
3250 W. Lower Buckeye Road, Suite 2100 Phoenix, Maricopa, Arizona, 85009
Business Address City, County, State, Zip Code
This Agreement between AHCCCSA and the entity identified above (“Group Biller”) is made pursuant to Titles XIX and
XXI of the Social Security Act and A.R.S. Title 36, Chapters 29 and 34 to govern: (1) registration of and payment to the
Group Biller on behalf of Affiliated Providers of health care services provided by the Affiliated Providers to AHCCCS
members on a fee-for-service basis and (2) registration for the Group Biller to participate in the Arizona Health Care Cost
Containment System through a Contractor.
As used in this Agreement:
“Affiliated Provider” means a provider of health care services who has authorized the Group Biller to act as its financial
representative.
“Contractor” has the same meaning as defined by A.R.S. § 36-2901(3).
In consideration of the covenants contained in this Agreement:
I. Fee-for-Service Patients
1. AHCCCSA agrees to make payments to the Group Biller on behalf of Affiliated Providers, consistent with State and
Federal law, the terms of this Agreement, and the AHCCCSA Capped Fee-For-Service Payment Schedule (including
amendments thereto and as hereby incorporated by reference), for health care services provided by Affiliated Providers to
fee-for-service patients.
2. For health care or medical services provided by Affiliated Providers to fee-for-service patients, the Group Biller
agrees to bill AHCCCSA in accordance with the terms of this Agreement, State and Federal law, and the following
documents, including amendments thereto, hereby incorporated by reference: the AHCCCS Fee-For-Service Billing
Manuals, the AHCCCS Medical Policy Manual, AHCCCS Claims Clues and other written directives provided by the
AHCCCSA to the Provider. These documents shall be made available to the Group Biller either in hard copy or via
AHCCCS Internet Website at www.ahcccs.state.az.us. The Group Biller shall conform its billing practices to ICD, CPT
and HCPCS compliance standards except when those standards conflict with AHCCCS policies defined listed above.
II. Participation through a Program Contractor or Health Plan
1. With respect to any services furnished by an Affiliated Provider to an AHCCCS member enrolled with a Contractor,
the terms and conditions of payment shall be as set forth in the contract between the Affiliated Provider and the Contractor
notwithstanding any inconsistent provisions of Section I of this Agreement.
2. The Group Biller agrees to hold AHCCCSA harmless, and agrees not to seek reimbursement from AHCCCSA, for
services rendered, pursuant to a contract between the Affiliated Provider and a Contractor, to AHCCCS members enrolled
with a Contractor.
III. General Terms and Conditions
The following terms and conditions apply both to services provided on a fee-for-service basis and services provided
through a Contractor:
1. Pursuant to 42 CFR 431.107, an Affiliated Provider is prohibited from participation in the Arizona Health Care Cost
Containment System unless a provider agreement with the Administration is in effect. The Group Biller shall not provide

group billing services to any provider who does not have in effect a Provider Agreement with AHCCCSA at the time
services are rendered.
2. The Group Biller shall ensure that every Affiliated Provider has completed an AHCCCSA Provider Participation
Agreement, is registered with AHCCCSA, and has signed an AHCCCSA Group Billing Authorization form. Each Affiliated
Provider shall be considered part of the billing group until the Provider furnishes written notification of its termination of
the group billing arrangement to the AHCCCSA Provider Registration Unit.
3. The Group Biller shall include the individual Affiliated Provider’s AHCCCS Provider ID or National Provider Identifier
number on each claim submitted by the Group Biller on behalf of the Affiliated Provider.
4. When AHCCCSA issues an amendment to modify this Agreement or to modify documents incorporated by reference
as part of this Agreement, the provisions of such amendment will be deemed to have been accepted by the Group Biller 30
days after the date AHCCCSA provides notice of the amendment to the Group Biller unless the Group Biller notifies
AHCCCSA in writing within that timeframe that it refuses to accept the amendment. If the Group Biller provides such
notification, this Agreement terminates. AHCCCSA may notify the Group Biller of a modification to a document
incorporated by reference by posting the modification to the AHCCCS website.
5. The Group Biller shall not bill, nor attempt to collect payment directly or through a collection agency from a person
claiming to be AHCCCS eligible without first receiving verification from AHCCCSA that the person was ineligible for
AHCCCS on the date of service, or that services provided were not AHCCCS covered services. The Group Biller agrees to
abide by Arizona Administrative Code R9-22-702 prohibiting the Group Biller from charging, collecting, or attempting to
collect payment from an AHCCCS eligible person.
6. The Group Biller agrees to bill the AHCCCSA only after a potential third party payer has been billed and, after payment
has been received, to bill AHCCCSA the balance due only up to the limit of the AHCCCS member’s responsibility.
7. In addition to other remedies available under this Agreement, AHCCCS shall be entitled to offset against any amounts
due the Group Biller or its Affiliated Providers any overpayments, or expenses or costs incurred by AHCCCSA concerning
the Group Biller’s non-compliance with this Agreement. The rights and remedies of AHCCCSA under this contract are not
exclusive.
8. The Group Biller shall maintain all records relating to performance of this Agreement in compliance with all
specifications for record keeping established by AHCCCSA. All books and records shall be maintained in such detail as shall
reflect each service provided and all other costs and expenses of whatever nature for which payment is made to the Group
Biller. Such material shall be subject to inspection, audit or copying by the state, AHCCCSA, the U.S. Department of Health
and Human Services, any other authorized representative of the state or federal governments during normal business hours at
the Group Biller’s place of business. The Group Biller shall preserve and make available records for a period of five years
from the date of payment under this Agreement except: (1) if this Agreement is completely or partially terminated, the records
relating to the work terminated shall be preserved and made available for a period of five years from the date of any such
termination; and (2) records which relate to disputes, litigation or the settlement of claims arising out of this Agreement, or
costs and expenses of this Agreement to which exception has been taken by the state, shall be retained by the Group Biller
until such disputes, litigation, claims or exceptions have been disposed of. The Group Biller shall comply with all applicable
AHCCCS Rules and Audit Guide relating to the audit of the Group Biller's records and the inspection of the Group Biller's
facilities.
9. Each party (as "Indemnitor") agrees to defend, indemnify, and hold harmless the other party (as "Indemnitee") from
and against any and all claims, losses, liability, costs, or expenses (including reasonable attorney's fees) (hereinafter collectively
referred to as "Claims") arising out of bodily injury of any person (including death) or property damage, but only to the extent
that such Claims which result in vicarious/derivative liability to the Indemnitee are caused by the act, omission, negligence,
misconduct, or other fault of the Indemnitor, its officers, officials, agents, employees, or volunteers.
10. The Group Biller shall comply with all federal, State and local laws, rules, regulations, standards and executive orders
governing performance of duties under this Agreement, without limitation to those designated within this Agreement.
11. Confidential information shall be safeguarded pursuant to 42 CFR Part 431, Subpart F, A.R.S. §36-107, 36-2903, 41-
1959 and 46-135, any other applicable State and Federal laws, and AHCCCS and/or ALTCS Rules.
12. Any grievances filed by the Group Biller on behalf of Affiliated Providers shall be adjudicated in accordance with
AHCCCS Rules as published in the Arizona Administrative Code. The Group Biller agrees to waive attorneys’ fees in any
disputes against AHCCCS concerning this Agreement.
13. Upon thirty (30) days written notice, either party may voluntarily terminate this Agreement. AHCCCSA has the right
to terminate this Agreement, in whole or part, upon twenty-four (24) hours written notice when AHCCCSA deems the
health or welfare of a member is endangered; the Group Biller or its Affiliated Providers fail to comply with Federal and
State laws and regulations; or there is a cancellation, termination or material modification in any Affiliated Provider’s
qualifications to provide.
14. AHCCCSA may, by written notice to the Group Biller, terminate this Agreement if it is found, after notice and hearing
by the State, that gratuities in the form of entertainment, gifts, or otherwise were offered or given by the Group Biller, or any
agent or representative of the Group Biller, to any officer or employee of the State with a view towards securing a contract or
securing favorable treatment with respect to the awarding, amending or the making of any determinations with respect to the

performance of the Group Biller; provided, that the existence of the facts upon which the state makes such findings shall be in
issue and may be reviewed in any competent court. If the Agreement is terminated under this section, AHCCCSA shall be
entitled to a penalty, in addition to any other damages to which it may be entitled by law, and to exemplary damages in the
amount of three times the cost incurred by the Group Biller in providing any such gratuities to any such officer or employee.
15. The Group Biller shall comply with State Executive Order 99-4, incorporated by reference as part of this Agreement,
and Federal Order 11246 which prohibit discrimination based on of race, color, religion, sex, age, national origin or political
affiliation and Executive Order 13672 prohibiting discrimination based on sexual orientation and gender identity.
16. By signing this Agreement, the Group Biller certifies that it has not engaged in any violation of the Medicare Anti-
Kickback statute (42 USC §§1320a-7b) or the “Stark I” and “Stark II” laws governing related-entity referrals (PL 101-239 and
PL 101-432) and has not received compensation therefrom.
17. The Group Biller shall be fully responsible for all tax obligations, Worker's Compensation Insurance, and all other
applicable insurance coverage, for itself and its employees, and AHCCCSA shall have no responsibility or liability for any
such taxes or insurance coverage.
18. If the Group Biller discovers, or is made aware of, an incident of potential fraud or abuse, the Group Biller shall report the
incident to AHCCCS’ Office of the Inspector General.
19. The Group Biller agrees to submit, within thirty-five (35) days after the date of request by AHCCCSA or the U.S.
Department of Health and Human Services, full and complete information as to ownership, business transactions, and
criminal activity in accordance with 42 C.F.R. 455, Subpart B and State law.
20. The Parties agree this Agreement is subject to and incorporate by reference the statutory language of A.R.S. §38-511.
FOR AND ON BEHALF OF THE GROUP BILLER FOR AND ON BEHALF OF AHCCCSA
______________________________________ ______________________________________
Signature Date Authorization
______________________________________ ______________________________________
Typed Name Date
______________________________________ ______________________________________
Board of Supervisors, Chairman Provider Number Assigned
PROVAGR/4-96 9/2015