Common use of BASIS FOR REIMBURSEMENT Clause in Contracts

BASIS FOR REIMBURSEMENT. As compensation to CONTRACTOR for services provided pursuant to the Contract, COUNTY shall pay CONTRACTOR at the following Fee for Service rates of reimbursement; provided, however, the total of all payments to CONTRACTOR under this Contract and all other COUNTY contractors providing substance use disorder treatment services shall not exceed COUNTY’s Aggregate Amount Not to Exceed as set forth in the Referenced Contract Provisions of the Contract; and provided further, that CONTRACTOR’s costs are allowable pursuant to applicable COUNTY, federal, and state regulations. Furthermore, if CONTRACTOR is ineligible to provide services due to non-compliance with licensure and/or certification standards of the State or OCPD, ADMINISTRATOR may elect to reduce COUNTY’s Aggregate Amount Not to Exceed proportionate to the length of time that CONTRACTOR is ineligible to provide services. CONTRACTOR shall ensure compliance with all DMC billing and documentation requirements when entering Units of Service (UOS) into COUNTY IRIS system. ADMINISTRATOR may reduce, withhold or delay any payment associated with non-compliant billing practices or non-compliant licensure and/or certification. If Corrective Action Plans (CAP) are not completed within timeframes as determined by ADMINISTRATOR, payments may be reduced accordingly. 1. For DMC services provided pursuant to the Contract, COUNTY shall claim reimbursement to the State Medi-Cal unit on behalf of CONTRACTOR to the extent these services are eligible. 2. Proper DMC certification and enrollment with the Provider Enrollment Division (PED) of DHCS, through the Provider Application and Validation for Enrollment (PAVE) system is required. CONTRACTOR shall submit proof of enrollment for each new rendering provider as required by regulations. Failure to demonstrate provider enrollment within six (6) months of services being rendered shall result in disallowance of those services by pending providers. 3. CONTRACTOR shall submit appropriate DMC billing invoices to ADMINISTRATOR on a monthly basis. The monthly invoice(s) shall match what CONTRACTOR has entered into IRIS at the time of invoice submission. Supplemental invoice(s) can be submitted if CONTRACTOR has services not yet entered into IRIS at time of original submission. It is CONTRACTOR’s responsibility to ensure the monthly DMC billing invoice UOS that CONTRACTOR provided to ADMINISTRATOR for submission to the State Medi- Cal unit matches the UOS that CONTRACTOR entered into COUNTY IRIS system. a. In support of the monthly invoice, CONTRACTOR shall submit required UOS and Tracking Report as specified in the Reports Paragraph of this Exhibit A-1 to the Contract. ADMINISTRATOR shall use the UOS and Tracking Report to determine payment to CONTRACTOR as specified in this Payments Paragraph of this Exhibit A-1. b. If, at any time, CONTRACTOR’s ▇▇▇▇ ▇▇▇ does not match the monthly DMC billing invoice UOS, ADMINISTRATOR, will review with CONTRACTOR, and may hold the DMC billing invoice for processing until a corrected invoice is received with matching UOS. Licensed Physician $124.95 Clinical Nurse Specialist $100.05 Nurse Practitioner $100.05 Registered Pharmacist $100.05 Physician Assistant $87.45 Registered Nurse $83.70 Psychologist (Licensed or Waivered) $81.30 Occupational Therapist $75.00 LCSW (Licensed, Waivered or Registered) $71.25 MFT/LPCC (Licensed, Waivered or Registered) $71.25 Certified AOD Counselor $58.80 Licensed Vocational Nurse $57.45 Peer Support Specialists $55.05 Mental Health Rehabilitation Specialist $49.95 Other Qualified Practitioner $49.95 Licensed Psychiatric Technician $49.95 Medical Assistant $37.50 4. CONTRACTOR shall assume responsibility for any audit disallowances or penalties imposed on COUNTY by the State related to amounts or services claimed by COUNTY on behalf of CONTRACTOR. CONTRACTOR shall reimburse COUNTY for any such disallowances or penalties within thirty (30) calendar days of written notification by COUNTY.