Okaloosa County BOCC — 2013 meeting #1139 (date undetermined) — MEDICAID ORIGINAL 2009 — reading text

$12.95 12.95. $1 1.00.= Must be valid amount. Maximum value is 999.99. Must be > 0.00. Trip_Pickup_Date 9(08) 252 259 8 Trip pickup Numeric and valid date date CCYYMMDD Trip_Pickup_Time 9(04) 260 263 4 Trip pickup Numeric and valid time time HHMM (24 hour - 1:OOpm = 1300). Same as Reservation Pickup_ Time Trip_Dest_Address X(30) 264 293 30 Trip Length> 0 destination address Trip_DesLCity X(20) 294 313 20 Trip Length> 0 destination citv Trip_DesLCounty 9(02) 314 315 2 Trip Validated against attached . destination table countv Trip_Dest_Code X(01) 316 316 1 Trip Validated against attached destination table code Trip_Actual]ickup_Time 9(04) 317 320 4 Trip actual Numeric and valid time- pickup time HHMM (24 hour - 1:OOpm = 1300) Trip_ActuaLDropolCTime 9(04) 321 324 4 Trip actual Numeric and valid time- dropoff time HHMM (24 hour - 1:OOpm = 1300) Trip_Escort_Required X(01) 325 325 1 Trip escort = Yes Y, No N = reauired Trip_Medical Necessity X(25) 326 350 25 None Trip_MediKids .. X(01) 351 351 1 MediKids = Yes Y, No =N Indicator Footer Record (one per batch -last record in filel Total FieldName Format Begin End Positions DescriJ>!ion Edits RecordType X(01) 1 1 1 Footer Record Must = F Indicator CTC_EIN 9(09) 2 10 9 CTC Federal Numeric Emolover ID Batch_Number 9(09) 11 19 g Unique ID lor Numeric - Must match batch (batches Batch_Number in header with duplicate IDs record will be rejected) Total_Claims_Batch 9(04) 20 23 4 Total number 01 Entire file rejected if this claims in this batch lield does not equal file number of "G" records 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation PrOVider Contract Page 100 of 117  Trip Origin Code & Trip Dest Code Validation Table P Physician C Clinic L Laboratory H Hospital N Nursing Home 0 Dialysis 0 Other Diagnosis or Therapeutic R Residence Trip Trans Mode Validation Table Trip Indicator Validation Table 2008/2009 Medicaid Non·Emergency Transportation Subcontracted Transportation Provider Contract Page 101 of 117  R I Return county Validation Table 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 102 of 117  ATIACHMENT 4 QUARTERLY GRIEVANCE SYSTEM SUMMARY REPORT STP Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Dates of Quarter Reporting:, ___________ Report is due 30 Calendar Days after the end of the reporting quarter. STP must report all data until closed. 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 103 of 117  ATTACHMENT 5 TRIP TRAVEL EXPENSE REPORT STP Name: _ _ _ _ _ _ _ _ _ _ _ _ _ __ Reporting Period: _ _ _ _ _ _ _ _ _ _ _ _ __ Due to the Commission 15 Calendar Days after the month in which the travel occurred. 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 104 of 117  ATTACHMENT 6 BUSINESS DISRUPTION NOTIFICATION REPORT STPName: _______________________________ Reporting Period: ________________ Coun~: ________________________________ System(s) Affected Description of Outage Population Affected Computer System Telephony System The date and time the incident occurred What event triggered the . incident The plan of action to bring the System back online . - - .. The expected date and time of recovery of full use of the System The impact the outage had on Medicaid Beneficiaries 2008/2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 105 of 117  ATTACHMENT 7 CRITICAL INCIDENT REPORT STP Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Reporting Period: _ _ _ _ _ _ _ _ _ _ _ _ __ County of Incident: Time of Incident: Location of Incident: Critical Incident Type: Details of Incident (Include Medicaid Beneficiary's age, gender, diagnosis, current medication, source of information, al! reported details , about the event, action taken by Commission/Subcontractor/Transportation Provider, and any other pertinent information): Follow Up Planned or Required (Include information relating to any Commission/Subcontractor/Transportation Provider policy or procedure that applies to the event): Transportation Provider: Report Submitted By: Date of Submission: 2008/2009 Medicaid Non·Emergency Transportation Subcontracted Transportation· Provider Contract Page 106 of 117  AlTACHMENT 8 DEFINITIONS AND ACRONYMS A. Definitions The following terms as used in this Agreement shall be construed and/or interpreted as follows, unless the Agreement otherwise expressly requires a different construction and/or interpretation. Abuse - Practices that are inconsistent with generally accepted business or Transportation practices and that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or services that are not Medically Necessary or that fail to meet professionally recognized standards for health care; or Medicaid Beneficiary practices that result in unnecessary cost to the Medicaid program. Action - (i) The denial or limited authorization of a requested service, including the type or level of service, pursuant to 42 CFR 438.400(b). (ii) The reduction, suspension, or termination of a previously authorized service. (iii) The denial, in whole or in part, of payment for a service. (iv) The failure to provide services in a timely manner, as defined by the State. (v) The failure of the Recipient to resolve a Complaint within fifteen (15) Business Days, a Grievance within ninety (90) Calendar Days, and an Appeal within forty-five (45) Calendar Days from the date the Recipient/Subcontractor receives the Complaint, Grievance, or Appeal. Acute Condition - An Acute Condition is a medical condition with a rapid onset of symptoms and/or a temporary or limited duration (as opposed to a Chronic Condition) and includes subacute conditions. Treatment for an Acute Condition is intended to last a short duration and may include surgical treatment, rehabilitative treatment, and/or other care. Agency - State of Florida, Agency for Health Care Administration. Agent - An entity that contracts with the State to perform administrative functions, including but not limited to: Fiscal Agent activities, outreach and education, eligibility activities; Systems and technical support. Agreement - The Agreement between the Recipient and the Agency to provide Medicaid Non-Emergency Transportation Services to Medicaid Beneficiaries, comprised of the Agreement, and any addenda, appendices, attachments,or amendments thereto. Agreement Period - The term of the Agreement from December 1, 2008 through August 31,2011. Agreement Year - The period of time from September 1 through August 31 of each calendar year. There are three (3) Agreement Years in this Agreement. The first (1st) Agreement Year shall run from December 1, 2008 through August 31, 2009. The second 200BI2009 Medicaid Non-Emergency Transportation Subcontracted Transportation Provider Contract Page 107 of 117  (2nd) Agreement Year shall run from September 1, 2009 through August 31, 2010. The third (3rd) Agreement Year shall run from September 1, 2010 through August 31, 2011. Appeal- A request for review of an Action, pursuant to 42 CFR 438.400(b). Attendant/Escort - An Attendant/Escort is an individual whose presence is required to assist a Medicaid Beneficiary during transport and at the place of treatment. .