C-86-16 IGA ORAL HEALTH FOR THIRD PARTY.PDF

INTERGOVERNMENTAL AGREEMENT (ADHS16-123017)
MARICOPA COUNTY
by and through the
DEPARTMENT OF PUBLIC HEALTH
4041 N. Central Avenue, #1400, Phoenix, Arizona 85012
1. Agreement No: C-86-16- 2. Agreement Type: Fixed Price
3. Agreement Amount: _$108,264.00 4. Purpose: Third Party Reimbursement for
Fluoride Varnish Services
5. Start Date: July 1, 2015 6. Expiration Date: June 30, 2016
This Agreement is entered into by and between the Arizona Department of Health Services (ADHS), (referred to herein as
“Contractor”), and Maricopa County, by and through its Department of Public Health (MCDPH) (referred to herein after as
“County”). Contractor and the County are collectively referred to herein as the “Parties” and individually as a “Party.”
Contractor, for and in consideration of the covenants and conditions set forth herein, shall provide and perform the services as
set forth below. All rights and obligations of the Parties shall be governed by the terms of this Agreement, its exhibits,
attachments, and appendices, including any subcontracts or amendments as set forth herein and in:
Section I - General Provisions Section III - Work Statement
Section II - Special Provisions Section IV - Compensation
This Agreement contains all the terms and conditions agreed to by the Parties. No other understanding, oral or otherwise,
regarding the subject matter of this Agreement shall be deemed to exist or to bind the Parties. Nothing in this Agreement shall
be construed as consent to any lawsuit or waiver of any defense in a lawsuit brought against the County or the Contractor in any
State or federal Court.
Legal Notice under this Agreement shall be given by personal delivery or by registered or certified mail, postage prepaid, return
receipt requested, to the addresses set forth below and shall be effective upon receipt by the Party to whom addressed unless
otherwise indicated in the notice.
Notice to Contractor: Arizona Department of Health Services (ADHS) Address:
Notice to Department: MCDPH Grants/Contract Unit Phone: (602) 372-0674
Address: 4041 North Central Avenue, Ste #1400, Phoenix, Arizona 85012
IN WITNESS WHEREOF, the parties enter into this Agreement:
ARIZONA DEPARTMENT OF HEALTH SERVICES MARICOPA COUNTY BOARD OF SUPERVISORS
Arizona Department of Health Services has authority to contract for
services specified herein in accordance with A.R.S. §§ 11-951, 11-952, 36-
104 and 36-132.
Signature Signature
Name Name
Title Title Chairman, Board of Supervisors
Date Date
ATTEST:
Signature
Clerk of the Board
Date
Pursuant to A.R.S. § 11-952, the undersigned public agency Pursuant to A.R.S. § 11-952, the Attorney for the Board of
attorney has determined that this Intergovernmental Supervisors has determined that this Intergovernmental
Agreement is in proper form and is within the powers and Agreement is within the powers and authority granted under the
authority granted under the laws of the State of Arizona. laws of the State of Arizona.
Signature Signature
Attorney for Maricopa County
Date Date
1

SECTION I GENERAL PROVISIONS
1. EFFECT
To the extent the Special Provisions are in conflict with the General Provisions, the
Special Provisions shall control. To the extent the Work Statement(s) and the Special or
General Provisions are in conflict, the Work Statement(s) shall control.
2. DEFINITIONS
As used throughout this Agreement, the following terms shall have the following
meanings:
A. Agreement means this document and all attachments and amendments hereto.
B. Contractor means the person, firm or organization listed on the Cover Page of
this Agreement.
C. County means Maricopa County, Arizona.
D. Department means the Maricopa County Department of Public Health.
E. Funding Source means any federal, State, or private agency funding source,
which may impose conditions on the funding that will be passed on to the
Contractor.
3. GENERAL REQUIREMENTS
A. The terms of this Agreement shall be construed in accordance with Arizona law.
Any lawsuit arising out of this Agreement shall be brought in the appropriate
court in Maricopa County.
B. The Contractor shall, without limitation, obtain and maintain all licenses, permits,
and authority necessary to do business, render services, and perform work under
this Agreement, and shall comply with all laws regarding unemployment
insurance, disability, and workers’ compensation.
C. The Contractor is an independent contractor in the performance of work and the
provision of services under this Agreement and is not to be considered an officer,
employee, or agent of the County.
4. AMENDMENTS
All Amendments to this Agreement must be in writing and signed by authorized persons
for both Parties. All amendments shall clearly state the effective date of the action.
5. ADEQUACY OF RECORDS
If the Contractor's books, records and other documents related to this Agreement are not
sufficient to support and document that allowable services were provided to eligible
clients, the Contractor shall reimburse the County for the services not adequately
supported and documented.
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SECTION I GENERAL PROVISIONS
6. RETENTION OF RECORDS
A. This provision applies to all financial and programmatic records, supporting
documents, statistical records, and other records of the Contractor that relate to
this Agreement.
B. The Contractor shall retain all financial books, records, and other documents
related to this Agreement for five (5) years after final payment or until after the
resolution of any audit questions, which could be more than five (5) years,
whichever is longer. County, federal, or State auditors, and any other persons
duly authorized by the County, shall have full access to and the right to examine,
copy and make use of any and all such financial books, records and other
documents.
7. ASSIGNMENT AND SUBCONTRACTING
No rights, liability, obligations or duties under this Agreement may be assigned,
delegated, or subcontracted without the prior written approval of the County.
8. AUDIT DISALLOWANCES
A. The Contractor shall, upon written demand therefore, reimburse the County for
any payments made under this Agreement that are disallowed, by a federal,
State or County audit in the amount of the disallowance, as well as court costs
and attorney fees the County incurs to pursue legal action relating to a
disallowance.
B. If the County determines that a cost for which payment has been made is a
disallowed cost, the County shall notify the Contractor in writing of the
disallowance and the required course of action, which shall be at the option of
the County either to adjust any future claim submitted by the Contractor by the
amount of the disallowance or to require immediate repayment of the disallowed
amount by the Contractor.
9. AGREEMENT COMPLIANCE MONITORING
County shall monitor the Contractor's compliance with, and performance under, the
terms and conditions of this Agreement. On-site visits for compliance monitoring may be
made by the County and/or its grantor agencies at a time agreed to by both parties and
during the Contractor's normal business hours. During an on-site visit, the Contractor
shall make its records and documents related to work performed or services provided
under this Agreement available to the County for inspection and copying.
10. AVAILABILITY OF FUNDS
A. The provisions of this Agreement relating to the payment for services shall
become effective when funds assigned for the purpose of compensating the
Contractor, as provided herein, are actually available to the County for
disbursement. The County shall be the sole authority in determining the
availability of funds under this Agreement and the County shall keep the
Contractor fully informed as to the availability of funds.
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SECTION I GENERAL PROVISIONS
B. If any action is taken by any State agency, federal department, or any other
agency or instrumentality to suspend, decrease, or terminate its fiscal obligations
under or in connection with this Agreement, the County may amend, suspend,
decrease, or terminate its obligations under or in connection with this Agreement.
If this Agreement is terminated, the County shall be liable for payment only for
services rendered prior to the effective date of the termination, provided that such
services are performed in accordance with the provisions of this Agreement. The
County shall give written notice of the effective date of any suspension,
amendment, or termination under this section at least ten (10) days in advance.
11. CONTINGENCY RELATING TO OTHER CONTRACTS AND GRANTS
A. The Contractor shall, during the term of this Agreement, immediately inform the
County in writing of the award of any other contract or grant where the award of
such contract or grant may affect either the direct or indirect costs being paid or
reimbursed under this Agreement. Failure by the Contractor to notify the County
of such award shall be considered a material breach of this Agreement and the
County may immediately terminate this Agreement without liability.
B. County may request, and the Contractor shall provide within a reasonable time,
not exceeding ten (10) working days, a copy of such other contract or grant,
when, in the opinion of the Department, the award of the contract or grant may
affect the costs being paid or reimbursed under this Agreement.
C. If the County determines that the award to the Contractor of such other contract
or grant has affected the costs being paid or reimbursed under this Agreement,
the County shall prepare an amendment to this Agreement effecting a cost
adjustment. If the Contractor disputes the proposed cost adjustment, the dispute
shall be resolved pursuant to the "Disputes" clause section contained herein.
12. DEFAULT
The County may suspend, modify, or terminate this Agreement immediately upon giving
written notice to the Contractor if the Contractor fails to perform under or otherwise
breaches any obligation under this Agreement, or upon the occurrence of any event that
may jeopardize the ability of the Contractor to perform any of its obligations under this
Agreement.
13. TERMINATION
A. Either Party may terminate this Agreement at any time by giving the other Party
at least thirty (30) calendar days prior written notice. The notice shall be given by
personal delivery or by registered or certified mail, postage prepaid, return
receipt requested.
B. This Agreement may be terminated by mutual written agreement of the Parties
specifying the termination date therein.
C. The County may terminate this Agreement upon twenty-four (24) hours notice
when the County deems the health or welfare of a patient is endangered or the
Contractor’s non-compliance jeopardizes funding source financial participation. If
not terminated by one of the above methods, this Agreement will terminate on
June 30, 2018, as stated on the Cover Page of this Agreement.
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SECTION I GENERAL PROVISIONS
14. SEVERABILITY
Any provision of this Agreement that is determined to be invalid, void, or illegal by a
court shall in no way affect, impair, or invalidate any other provision hereof, and the
remaining provisions shall remain in full force and effect.
15. STRICT COMPLIANCE
Acceptance by the County of performance that is not in strict compliance with the terms
of this Agreement shall not be deemed to waive the requirement of strict compliance for
all future performance. All changes in performance obligations under this Agreement
must be in writing and signed by the Parties.
16. NON-LIABILITY
The County and its officers, representatives, agents, and employees shall not be liable
for any act or omission by the Contractor or any subcontractor, employee, officer, agent,
or representative of the Contractor or any subcontractor occurring in the performance of
this Agreement, nor shall they be liable for purchases or contracts made by the
Contractor or any subcontractor in connection with this Agreement.
17. INDEMNITY
Each Party (as “Indemnitor”) agrees to indemnify, defend, and hold harmless the other
Party (as “Indemnitee”) from and against all claims, losses, liability, costs, and expenses
(including reasonable attorneys’ 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 liability to Indemnitee, are
caused by the act, omission, negligence, misconduct, or other fault of Indemnitor, its
officers, agents, employees, or volunteers.
18. COVENANT AGAINST CONTINGENT FEES
The Contractor warrants that no person or entity has been employed or retained to solicit
or secure this Agreement upon an agreement or understanding for a commission,
percentage, brokerage, or contingent fee. For breach or violation of this warranty, the
County may immediately terminate this Agreement without liability.
19. SAFEGUARDING CLIENT INFORMATION
The use or disclosure by any Party of any information concerning an eligible individual
served under this Agreement is directly limited to the performance of this Agreement.
20. RIGHTS IN DATA
The Parties shall have the use of data and reports resulting from this Agreement without
cost or other restriction, except as otherwise provided herein or by law. Each Party shall
supply to the other Party, upon request, any available information known to the
supplying Party that is relevant to this Agreement and to the performance hereunder.
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SECTION I GENERAL PROVISIONS
21. NON-DISCRIMINATION
The Contractor, in connection with any service or other activity under this Agreement,
shall not in any way discriminate against any person on the grounds of race, color,
religion, sex, national origin, age, disability, affiliation or belief. The Contractor shall
include this clause in all of its subcontracts related to this Agreement.
22. EQUAL EMPLOYMENT OPPORTUNITY
The Contractor shall not discriminate against any employee or applicant for employment
because of race, age, disability, color, religion, sex, or national origin. The Contractor
shall take affirmative action to insure that applicants are employed and that employees
are treated during employment without regard to their race, age, disability, color, religion,
sex, or national origin. Such action shall include, but is not limited to, the following:
employment, upgrading, demotion or transfer, recruitment or recruitment advertising, lay-
off or termination, rates of pay or other forms of compensation, and selection for training,
including apprenticeship. The Contractor shall, to the extent such provisions apply,
comply with Titles VI and VII of the Civil Rights Act of 1964, as amended (42 U.S.C. §§
2000a, et seq.); the Rehabilitation Act of 1973, as amended (29 U.S.C. §§ 701, et seq.);
the Age Discrimination in Employment Act of 1967, as amended (29 U.S.C. §§ 621, et
seq.); the Immigration Reform and Control Act of 1986 (Pub. L. No. 99-603) (“IRCA”);
and Arizona Executive Order 2009-09, which mandates that all persons shall have equal
access to employment opportunities. The Contractor shall also comply with all
applicable provisions of the Americans with Disabilities Act of 1990 (42 U.S.C. §§ 12101,
et seq.).
23. RIGHT OF PARTIAL CANCELLATION
If more than one activity is funded by this Agreement, the County reserves the right to
terminate this Agreement or any part thereof based on the Contractor's failure to perform
any part of this Agreement without impairing, invalidating or canceling the remaining
Work Statement obligations.
24. RIGHT TO EXTEND AGREEMENT
Subject to the availability of funds and acceptable Contractor performance, the
Contractor hereby acknowledges and agrees that the County shall have the right to
extend this Agreement for additional one-year periods, not to exceed a total extended
term of five (5) years, except that the cost will be subject to renegotiation. Any extension
of this Agreement shall be in writing mutually acceptable to the Department and the
Contractor and signed by both Parties.
25. CERTIFICATION REGARDING DEBARMENT AND SUSPENSION
A. The undersigned, an authorized representative of the Contractor, certifies, to the
best of his or her knowledge and belief, that the Contractor, defined as the
primary participant in accordance with 45 C.F.R. Part 76, and its principals:
1) are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded from covered transactions by any federal
department or agency;
2) have not within the 3-year period preceding this Agreement been convicted of
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SECTION I GENERAL PROVISIONS
or had a civil judgment entered against them for the commission of fraud or a
criminal offense in connection with obtaining, attempting to obtain, or performing
a public (federal, State or local) transaction or contract under a public
transaction; violation of federal or State antitrust statues or commission of
embezzlement, theft, forgery, bribery, falsification or destruction of records,
making false statements, or receiving stolen property;
3) are not presently indicted or otherwise criminally or civilly charged by a
government entity (federal, State or local) with the commission of any of the
offenses enumerated in paragraph (2) of this certification; and
4) have not within the 3-year period preceding this Agreement had one or more
public transactions (federal, State or local) terminated for cause or default.
B. If the Contractor is not able to provide this certification, an explanation as to why
shall be attached to this Agreement.
C. The Contractor shall include, without modification, this Paragraph in all lower tier
covered transactions (i.e., transactions with subcontractors) and in all
solicitations for lower tier covered transactions related to this Agreement.
26. E-VERIFICATION OF EMPLOYEES
The Contractor warrants that it is in compliance with A.R.S. § 41-4401 and further
acknowledges:
A. That the Contractor and its subcontractors, if any, warrant their compliance with
all federal immigration laws and regulations that relate to their employees and
their compliance with A.R.S. § 23-214;
B. That a breach of the warranty under subsection A above shall be deemed a
material breach of this Agreement that entitles the County to, among other
things, immediately terminate this Agreement without liability;
C. That the County and any contracting government entity retains the legal right to
inspect the papers of any contractor or subcontractor employee who works on
this Agreement to ensure that the contractor or subcontractor is complying with
the warranty provided under subsection A above and that the contractor agrees
to make all papers and employment records of said employee(s) available during
normal working hours in order to facilitate such an inspection;
D. That nothing herein shall make any contractor or subcontractor an agent or
employee of the County or contracting government entity.
27. DISPOSITION OF PROPERTY
All property acquired with funds provided for in this agreement shall become the property
of the funding source.
28. ARBITRATION
Pursuant to A.R.S. § 12-1518, disputes under this Contract shall be resolved through the
use of arbitration when the case or lawsuit is subject to mandatory arbitration pursuant to
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SECTION I GENERAL PROVISIONS
rules adopted under A.R.S. § 12 -133.
8

SECTION II SPECIAL PROVISIONS
1. EFFECT
To the extent that the Special Provisions are in conflict with the General Provisions, the
Special Provisions shall control. To the extent that the Work Statement(s) are in conflict
with the Special or General Provisions, the Work Statement(s) shall control.
2. DISPUTES
Except as otherwise provided by law, or otherwise specifically agreed to by the Parties,
any dispute not involving a question of law arising out of this Agreement that is not
resolved between the Parties within a reasonable time, which shall not exceed 120 days,
shall be resolved as follows:
1. Disputes must be filed with the person administering this Agreement
for the County, if one has been appointed, or, if not, with the Procurement
Officer, within ten (10) days from the date the Contractor knew or should
have known the basis of the dispute.
2. The person administering this Agreement or the Procurement Officer,
as applicable, shall respond in writing to the dispute within fourteen (14)
days.
3. The Contractor may abide by the decision or may appeal the decision
to the Director of the Department within seven (7) days.
This Paragraph shall not apply to claims arising from bodily injury, death, or property
damage.
3. CHANGES
A. The Department may, at any time, by written order, and signed by the Contractor,
make changes within the general scope of this Agreement in any one or more of
the following areas:
1. Work Statement activities reflecting changes in funding source or County
regulations, policies, or requirements.
2. Administrative requirements, such as changes in reporting periods,
frequency of reports, or report formats, required by funding source or
County regulations, policies, or requirements.
3. Contractor reimbursement schedules and/or program budgets.
B. The order will not increase or decrease the maximum reimbursable amount to be
paid the Contractor. Additionally, the order will not direct substantive changes in
services to be rendered by the Contractor.
C. Any dispute or disagreement caused by such order shall constitute a "Dispute"
within the meaning of the Disputes Clause of the Special Provisions of this
Agreement and shall be administered accordingly.
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SECTION II SPECIAL PROVISIONS
4. AUDIT REQUIREMENT
A. If the Contractor expends $500,000 or more in a year in federal awards, the
Contractor shall have a single audit conducted for that year according to the
Single Audit Act of 1984 (Pub. L. No. 98-502) (codified at 31 U.S.C. §§ 7501, et
seq.), and the Single Audit Act Amendments of 1996 (Pub. L. No. 104-156). The
Contractor shall comply with OMB Circulars A-133, A-87, A-102, and A-110, as
applicable. The audit report shall be submitted to the County for review within
nine (9) months following the close of the fiscal year. The Contractor shall take
any necessary corrective action to remedy any material weaknesses and/or
reportable conditions identified in the audit report within six (6) months after the
release date of the report. The County may consider sanctions as described in §
.225 of OMB Circular A-133 for contractors not in compliance with the audit
requirements. All books and records shall be maintained in accordance with
Generally Accepted Accounting Principles (GAAP).
B. Comply with the requirement of the Federal Office of Management and Budget
(“OMB”) Circular A-133. The Contractor is responsible for having an audit
performed in accordance with, and when required, by OMB Circular A-133, and
for sending a copy of the report issued as a result of the audit to the County
within thirty (30) days of issuance. The County reserves the right to engage an
auditor, at the Contractor’s expense, to perform an OMB Circular A-133 audit of
the Contractor in the event that the Contractor fails to engage an auditor or the
County rejects or disapproves of the auditor engaged by the Contractor.
5. INSURANCE
A. The Contractor shall have in effect at all times during the term of this Agreement
insurance or comparable self-insurance that is adequate to protect the County,
its officers, employees, property, and equipment against the losses set forth
below. The Contractor shall provide the County with a certificate of insurance or
a certified copy of the insurance policy naming the County as an additional
insured, or, if the Contractor is self-insured, shall provide the County with a letter
indicating that it is self-insured.
B. The following types and amounts of insurance are required as minimums:
1. Workers’ compensation and unemployment insurance as required by law.
2. Unemployment insurance as required by Arizona law.
3. Public liability, bodily injury, and property damage policies that insure
against claims for liability for the Contractor’s negligence or maintenance
of unsafe vehicles, facilities, or equipment brought by clients receiving
services pursuant to this Agreement and by lawful visitors of such clients.
The limits of the policies shall not be less than $2,000,000 per occurrence
and $4,000,000 aggregate.
C. Automobile and Truck Liability, Bodily Injury and Property Damages:
1. General liability, each occurrence; $1,000,000
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SECTION II SPECIAL PROVISIONS
2. Property damage; $1,000,000
3. Combined single limit; $1,000,000
D. Standard minimum deductible amounts are allowable. Any losses applied
against insurance deductible are the sole responsibility of the Contractor.
E. Professional Liability:
1. Insurance for the Contractor and its agents, employees, and other staff
shall be maintained with coverage limits of one million dollars
($1,000,000) per person, three million dollars ($3,000,000) per
occurrence.
2 The Contractor agrees that in the event it, or any of its agents,
employees, and other staff working under this Agreement, is named as a
defendant in litigation, or is identified in a written notice of claim, wherein
professional misconduct is alleged, the Contractor will promptly notify the
Department in writing. The duty to notify under this paragraph applies
whether or not the County is alleged to be involved, is named as a party
to the matter, or could be potentially liable as a party.
F. The Contractor shall immediately inform the Department of any cancellation of its
insurance or any decrease in its lines of coverage at least thirty (30) days before
such action takes place.
6. SPECIAL REQUIREMENTS
A. If the use of subcontractors is approved by the County, the Contractor agrees to
use written subcontracts or consultant agreements that conform to federal and
State laws and regulations and the requirements of this Agreement appropriate
to the service or activity covered by the subcontract. These provisions apply with
equal force to the subcontract as if the subcontractor were the Contractor. The
Contractor is responsible for performance under this Agreement whether or not
any subcontractors are used. The Contractor shall submit a copy of each
subcontract to the County within fifteen (15) days of its effective date.
B. The Contractor shall include in any subcontracts a provision to the effect that the
subcontractor agrees that the County shall have access to the subcontractor’s
facilities and the right to examine any books, documents, and records of the
subcontractor involving transactions related to the subcontract, and that such
books, documents, and records shall not be disposed of except as provided
herein.
7. REPORTING REQUIREMENTS
If requested by the County, the Contractor shall submit quarterly progress reports on or
before the third (3rd) day of the month following the end of the reporting period. In
addition, a quarterly expenditure report will be submitted with the quarterly progress
report.
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SECTION II SPECIAL PROVISIONS
8. STATUTORY RIGHT OF CANCELLATION FOR CONFLICT OF INTEREST
Pursuant to A.R.S. § 38-511, the County may cancel this Agreement without penalty or
further obligation, within three years after execution of this Agreement, if any person
significantly involved in initiating, negotiating, securing, drafting, or creating this
Agreement on behalf of the County is, at any time while this Agreement or any extension
of this Agreement is in effect, an employee or agent of any other Party to this Agreement
in any capacity or is a consultant to any other Party to this Agreement with respect to the
subject matter of this Agreement. In addition, the County may recoup any fee or
commission paid or due to any person significantly involved in initiating, negotiating,
securing, drafting, or creating this Agreement on behalf of the County from any other
Party to this Agreement arising as the result of this Agreement.
Pursuant to A.R.S. § 38-511, the State may cancel this Contract within three (3) years
after Contract execution without penalty or further obligation if any person significantly
involved in initiating, negotiating, securing, drafting or creating the Contract on behalf of
the State is, or becomes at any time while the Contract or an extension of the Contract is
in effect, an employee of or a consultant to any other party to this Contract with respect
to the subject matter of the Contract. The cancellation shall be effective when the
Contractor receives written notice of the cancellation, unless the notice specifies a later
time. If the Contractor is a political subdivision of the State, it may also cancel this
Contract as provided in A.R.S. § 38-511.
9. POLICY ON CONFIDENTIALITY
The Contractor and the County understand and agree that this Agreement is subject to
all State and federal laws protecting client confidentiality of medical, behavioral health
and drug treatment information.
10. LAWS, RULES AND REGULATIONS
The Contractor and the County understand and agree that this Agreement is subject to
all State and federal laws, rules, and regulations that pertain hereto.
11. SPONSORSHIP ACKNOWLEDGMENT
If applicable, all promotional materials, brochures, and flyers prepared by the Contractor
shall include this statement, “Sponsored by the Maricopa County Department of Public
Health”.
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SECTION III WORK STATEMENT
1. BACKGROUND
The United States Surgeon General’s report in the year 2000 identified dental caries
(tooth decay) as one of the most common chronic diseases of childhood. Caries is the
most common chronic disease seen in children, and is easily prevented through proper
use of topical fluoride.
Children who are at greatest risk for caries are those from low income and minority
populations and are least likely to have access to dental care. The American Academy
of Pediatric Dentistry and the American Dental Association recommend the first dental
visit occur no later than twelve (12) months of age. Children can develop caries as soon
as teeth erupt which can cause pain and prevent them from being able to eat, speak,
sleep and learn properly. Some deciduous or “baby teeth” are retained until
adolescence. Dental caries can often be reversed or arrested in the earliest stages with
the application of topical fluoride. Once the decay progresses and the longer the decay
remains untreated, the more difficult and costly it becomes to repair. As a result, early
intervention and prevention is easier for both the child and the dental professional, less
expensive, and more successful than treatment at a later time.
Health education and promotion can be an important piece of any public health initiative
as many low income people do not understand the importance of seeking care or
preventive services. The knowledge that dental caries is a transmissible disease caused
by bacteria or that simple behavior changes can limit the risk of caries, is not widespread
among the general population, let alone low income people. Collaborative efforts with
agencies or groups such as Head Start centers, Women Infant and Children (WIC)
centers or coalition groups can play a significant role in improving the education and
awareness of community members.
National objectives help guide States in promoting health and wellness through such
guidelines as the Healthy People 2020 oral health objectives. These objectives include:
A. OH-1: Reduce the proportion of children and adolescents who have dental caries
experience in their primary or permanent teeth.
B. OH-2: Reduce the proportion of children and adolescents with untreated dental
decay.
C. OH-7: Increase the proportion of children and adolescents who used the oral
health care system in the past twelve (12) months.
D. OH-8: Increase the proportion of low-income children and adolescents who
received any preventive dental service during the past year.
Fluoride varnish application is a safe, cost-effective procedure to prevent dental caries.
Bacteria that build up on tooth surfaces produce acids that de-mineralize enamel. Left
unchecked, the bacteria continue to destroy tooth structure. Fluoride varnishes are
applied directly to the tooth surface and provide immediate "re-mineralization", interfere
with bacterial build- up and reduce acid production. According to an Association of State
and Territorial Dental Directors (ASTDD) Research Brief (2007) studies on fluoride
varnish have demonstrated that at least two fluoride applications per year for a period of
two years are necessary to demonstrate effective reductions in tooth decay. Fluoride
varnish is an adjunct to community water fluoridation or dietary fluoride supplements.
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SECTION III WORK STATEMENT
2. OBJECTIVE
Maricopa County Department of Public Health (MCDPH) Office of Oral Health (OOH) will
partner with Arizona Department of Health Services (ADHS) Office of Oral Health to
provide billing services for the First Teeth First (FTF) program throughout Maricopa
County.
3. SCOPE OF SERVICES
Arizona Department of Health Services (ADHS) shall provide services related to billing
and reimbursement for fluoride varnish services rendered through the First Teeth First
(FTF) program. Provision of services will be based on availability of funding.
4. TASKS
The Contractor (ADHS) shall:
A. The Arizona Department of Health Services, Office of Oral Health will provide a
model for cost re-imbursement structure for those children who are served by the
MCDPH at program sites who are also AHCCCS eligible.
B. ADHS will enter data collected on the encounter forms provided by MCDPH.
C. ADHS will maintain a web-based application to house and report on oral health
indicators collected on the current MCDPH data forms.
D. The application will collect the following data elements:
1. Demographic information to include name, date of birth, race/ethnicity
2. insurance status
3. health history
4. oral health surveillance indicators
5. dental findings
6. dental treatment
7. dental referrals
8. dental provider
9. billing information
E. ADHS-OOH will submit to AHCCCS all information required by Arizona Health
Care Cost Containment System (AHCCCS) and AHCCCS health plans for
enrollment of dentists and/or Affiliated Practice dental hygienists into the
program.
F. Arizona Department of Health Services, Office of Oral Health, will submit ADA
claim forms to the appropriate AHCCCS health plans for eligible dental services
provided by the MCDPH in accordance with the First Things First fluoride varnish
strategy.
G. Maintain current database application as structured under the Frist Things First
South Phoenix pilot.
H. Adhere to HIPAA compliance and First Things First Data Security Guidelines.
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SECTION III WORK STATEMENT
I. Submit fluoride varnish claims for the First Teeth First program to meet timely
filing as required by the specific payer.
J. Provide Maricopa County Office of Oral Health (MCOOH) with monthly invoices
for services.
K. Provide Maricopa County Office of Oral Health (MCOOH) First Teeth First (FTF)
program with quarterly reports on the 15th of the following month at the close of
each quarter and they will include the following:
1. Number of children screened
2. Number of children who received a fluoride varnish
3. Number AHCCCS Eligible Children
4. Number of Claims Billed by Date of Service
5. Number of Claims Reimbursed by Date of Service
6. Number of Claims Denied by Date of Service
L. Provide Maricopa County Office of Oral Health (MCOOH) with funds from billing
service along with quarterly reports on the 15th of the following month at the close of
each quarter.
5. MCOOH-FTF shall:
A. Provide consent forms and treatment records to ADHS bi-monthly for billing
purposes;
B. Ensure dental providers are properly credentialed and documented;
C. Submit all information required by Arizona Health Care Cost Containment
System (AHCCCS) and AHCCCS health plans for enrollment of dentists and/or
Affiliated Practice dental hygienists into the program. This AHCCCS Provider
Information shall be submitted to ADHS-OOH thirty (30) days prior to a dentist
and/or AP dental hygienist providing service in the program. The information
shall include the following:
1. Arizona current license to practice dentistry,
2. State of Arizona Substitute W-9 & Vendor Authorization form,
3. AHCCCS Provider Registration form,
4. AHCCCS Provider Participation Agreement, and
5. AHCCCS Group Authorization form.
6. REQUIREMENTS
The Contractor (ADHS) shall:
A. Maintain confidentiality;
1. All data, forms, and supporting documentation for the program-related
activities shall remain in the custody of ADHS to ensure compliance for billing
services. MCDPH may have access to original documentation if required,
with the intent of returning the original forms back in the care of ADHS;
2. Adhere to all HIPAA privacy and security rules;
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SECTION III WORK STATEMENT
3. Confidential patient and/or program information shall not be released or
discussed with anyone other than authorized individuals;
7. NOTICE, CORRESPONDENCE AND REPORTS
A. Notices, correspondence, reports, and invoices from the Contractor to MCOOH-
FTF shall be sent to:
Office of Oral Health
1645 East Roosevelt Street
Phoenix, Arizona 85006
Attn: Fluoride Varnish Program Manager
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SECTION IV COMPENSATION
1. COMPENSATION
A. The Contractor shall submit a monthly invoice by the 25th of the following month.
B. The Department shall, within thirty (30) working days from the date of receipt of
Contractor’s invoice, process and remit to the Contractor a warrant for payment.
Should the Department make disallowance in the claim, the claim shall be
processed to the reduced amount. The Contractor shall be notified at the address
below in writing of the amount and reasons for any disallowances, and shall be
afforded the opportunity to document the appropriateness of the disallowed costs
and to resubmit an invoice for payment.
C. Each Party assumes sole and exclusive responsibility for payment of any federal
and state income taxes, federal social security taxes, workers’ compensation,
and unemployment insurance benefits for its physicians, staff, agents, and
employees, as well as any and all other mandatory governmental deductions or
obligations.
D. The Agreement amount is not-to-exceed $108,264 for Year one (1). The
Agreement amount for each year of the subsequent years of the term will be
negotiated based on the availability of funds.
2. METHOD OF PAYMENT
A. All payment requests/invoices must be on Contractor letterhead and contain an
electronic signature authorizing the reimbursement request. The fixed amount
payable each month is $9,022.
B. The Contractor must maintain and have available upon request supporting
documents for each monthly reimbursement request, including invoices of costs
incurred and expenditure reports.
C. Subject to the availability of funds, the County will, within thirty (30) working days
from the date of receipt of documents enumerated herein, process and remit to
the Contractor a warrant for payment up to the maximum total allowable for
services provided. Should the County make a disallowance in the claim, the
claim shall be processed for the reduced amount. If the Contractor protests the
amount or the reason for a disallowance, the protest shall be construed as a
dispute concerning a question of fact within the meaning of the “Disputes” clause
of the Special Provisions of this Agreement.
D. The Contractor understands that claims for payment for services rendered prior
to the execution of this Agreement shall be submitted no later than sixty (60)
days after the expiration of the Agreement. Claims for payment submitted after
this time period will not be honored without the approval of the County.
.
E. Payments made by the County to the Contractor are conditioned upon the timely
receipt of applicable, accurate, and complete invoices submitted by the
Contractor. The Contractor forfeits the right to reimbursement for costs incurred
in any month for which it fails to meet the deadline for submitting the monthly
reports, except if such failure is beyond the reasonable control of the Contractor.
The Contractor also forfeits its right to reimbursement for costs incurred in which
a paid invoice or proof of expenditure is non-existent.
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SECTION IV COMPENSATION
F. The Contractor shall submit monthly invoices to:
Maricopa County Department of Public Health
Office of Oral Health
1645 East Roosevelt Street
Phoenix, Arizona 85006
Attn: Fluoride Varnish Program Manager
3. PAYMENTS
Payments shall be sent to the following addresses:
Arizona Department of Health Services
Cash Receipt (Oral Health Fluoride Varnish)
1740 W. Adams, Room 301
Phoenix, AZ 85007
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