C-86-12-005-3-05 AMD 5 DISTRICT MEDICAL GROUP.PDF

CONTRACT NO.: C-86-12-005-3-05 AMENDMENT NO. 5
AMENDMENT TO CONTRACT
Between
MARICOPA COUNTY
By and through
DEPARTMENT OF PUBLIC HEALTH
And
DISTRICT MEDICAL GROUP, an Arizona Corporation
I. The above named contract is hereby amended as specified below:
A. Cover Page, under 1.0 Contract Term, 1.1., the original contract shall be extended for an
additional (and final) one (1) year term, beginning on August 1, 2016 and ending July 31,
2017.
B. Replace Attachments B and C with the revised Attachments B and C.
II. All other terms and conditions of the original contract and its amendments shall remain in
full force and effect.
IN WITNESS WHEREOF, the parties agree to the changes indicated herein:
FOR AN ON BEHALF OF FOR AN ON BEHALF OF
MARICOPA COUNTY DISTRICT MEDICAL GROUP, an
Arizona Corporation
By________________________________ By________________________________
Clint Hickman, Chairman, Board of Supervisors
__________________________________ __________________________________
Date Date
ATTEST: ATTEST:
__________________________________ __________________________________
Clerk of the Board
__________________________________ __________________________________
Date Date
APPROVED AS TO FORM: APPROVED AS TO FORM:
__________________________________ __________________________________
Attorney for Maricopa County
__________________________________ __________________________________
Date Date
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CONTRACT NO.: C-86-12-005-3-05 AMENDMENT NO. 5
EXHIBIT B
Scope of Work:
A. Radiology Services
DMG will provide professional services as indicated: the reading, interpretation and
consultation of test results including limited radiology services to diagnose fractures,
respiratory conditions such as tuberculosis, and digestive complications, in addition to
ultrasound, mammography, MRI, CAT, and PET as ordered by providers at Healthcare for the
Homeless (HCH).
B. Specialty Care Services
Contractor shall provide an array of comprehensive and specialty services as set forth
below.
1. Physical Therapy, limited to 15 visits per year per patient, consistent with AHCCCS
benefit guidelines;
2. Surgery clinic services (includes Urology, General Surgery, Podiatry, Neurosurgery,
Radiology);
3. Internal Medicine Subspecialty clinic services (includes Rheumatology, Infectious
Disease, Gastroenterology, and Neurology);
4. Ophthalmology services
5. Obstetrics, Gynecology, and Reproductive Health (includes colposcopy services)
6. Cardiology services (includes cardiac stress, EKG, and ECHO testing)
7. ENT services
8. Orthopedic services
9. Colonoscopy Services
10. Oncology Services
11. Breast Clinic Services
12. Pediatric Specialty Services
C. Additional information
a. All services shall be pre-authorized and directed by the staff of the Maricopa County
Healthcare for the Homeless (HCH) program.
b. Contractor shall maintain client records in accordance with the Arizona Department
of Health Services (AZDHS) and HCH established policies and procedures.
c. Contractor shall provide HCH access to patient records for utilization review,
contract compliance, and quality assurance.
D. DMG will bill AHCCCS for patients who are AHCCCS enrolled prior to invoicing HCH. HCH
shall pay the AHCCCS patient cost share for any AHCCCS covered services. For patients or
services not covered by AHCCCS, the reimbursement to Contractor by HCH will be as
follows:
1. Reimbursement to DMG will be at 85% of the current Arizona Health Care Cost
Containment System (AHCCCS) fee-for-service rate for Ancillary Care Services in
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CONTRACT NO.: C-86-12-005-3-05 AMENDMENT NO. 5
effect on the date of service, not including any long term or ongoing specialty care.
2. For services not priced by AHCCCS, reimbursement shall be twenty percent (20%) of
Contractor’s billed charges.
3. Any procedure over $5000.00 will require approval of the HCH Clinic Supervisor.
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CONTRACT NO.: C-86-12-005-3-05 AMENDMENT NO. 5
EXHIBIT C
Healthcare for the Homeless – District Medical Group Invoice Billing Process
Invoice billing to be submitted monthly by District Medical Group (DMG) to Healthcare for the
Homeless (HCH) via a spreadsheet with the following data elements:
• Submitter’s Name and Address
• Unique Invoice number and description of submission including name and address of
Healthcare for the Homeless
• MIHS Patient Number (PID)
• Last Name
• First Name
• DOB
• HCPC (Billed Services)
• DMG Invoice Number
• Date of service
• Description of Service
• Billed Amount (from DMG Invoice)
• Amount due (discount to be determined by contract, i.e., 50% of billed amount)
• Grand Total
Invoices will be submitted no later than the 10th of the month for services provided in the
previous month. An electronic copy of the invoice will be sent via email and HCFC 1500 forms
with attached copies of authorizations and a hardcopy of the invoice will be delivered to HCH
for processing.
Services to be billed on the invoice will be identified solely by matching services to
authorizations that are sent to DMG. Any non-authorized services will not be billed to HCH and
are the responsibility of the patient if there is no other payer. HCH will identify a contact
person for DMG to clarify authorizations. DMG will monitor patient accounts to identify
insurance eligibility and will bill any covered services to the identified insurance carrier. These
covered services will not be included on the invoice for payment. DMG will continue to
monitor patient accounts for ninety (90) days from the date of service and if retro-eligibility
with insurance for a period inclusive of the date of service is identified, DMG will bill identified
insurance carrier for covered services and return to HCH payments for such covered services
previously paid by HCH.
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