HomeMy WebLinkAboutResolution_16-96/97_04/10/1997 RESOLUTION NO. 16 -9697
A RESOLUTION OF THE VILLAGE COUNCIL OF THE
VILLAGE OF TEQUESTA, PALM BEACH COUNTY,
FLORIDA, APPROVING AN ELECTRONIC DATA
INTERCHANGE AGREEMENT BETWEEN THE VILLAGE OF
TEQUESTA AND HEALTH CARE FINANCING
ADMINISTRATION (MEDICARE) AND AUTHORIZING
THE VILLAGE MANAGER TO EXECUTE THE SAME ON
BEHALF OF THE VILLAGE.
NOW, THEREFORE, BE IT RESOLVED BY THE VILLAGE COUNCIL OF THE
VILLAGE OF TEQUESTA, PALM BEACH COUNTY, FLORIDA, AS FOLLOWS:
Section 1. The Electronic Data Interchange Agreement
between Health Care Financing Administration (Medicare) and
the Village of Tequesta, attached hereto as Exhibit "A" and
incorporated by reference as a part of this Resolution, is
hereby approved and the Village Manager of the Village of
Tequesta is authorized to execute the same on behalf of the
Village of Tequesta.
THE FOREGOING RESOLUTION WAS OFFERED by Councilmember
Hansen , who moved its adoption. The motion was seconded
by Councilmember Mackail and upon being put to a vote,
the vote was as follows:
• FOR ADOPTION AGAINST ADOPTION
Joseph N. Capretta
Carl C. Hansen
Ron T. Mackail
Elizabeth A. Schauer
The Mayor thereupon declared the Resolution duly passed and
adopted this 10th day of April, A.D., 1997.
MAYOR OF TEQUESTA
Elizabeth A Schauer
ATTEST:
oann Mangani llo
i Village Clerk
wp60 \res \16 -97
Lt \lllli I l A
ELECTRONIC DATA INTERCHANGE AGREEMENT
• V ILLAGE OF TEQUESTA FIRE RESCUE
This Agreement between . (herein called
"provider ") and the Health Care Financing Administration , (herein called "HCFA "), is made as
of . 19____ and shall remain in effect until terminated.
( "Provider" means a hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility,
home health agency, hospice, physician, or supplier as defined in 42 C.F.R. s400.202 or physician
as defined in s1861(r) of the Act.)
The provider and HCFA desire to facilitate, through the use of electronic formats, claims submission
and payment by electronically transmitting and receiving data that are in specific machine readable
formats. HCFA and the provider intend such transactions to be legally valid and enforceable.
A. The Provider Agrees:
1. That it shall be liable for any and all breaches of this Agreement that may be committed
by any partner, director, officer, employee, servant, agent, or subcontractor of the provider. The
provider agrees further that the terms "agent" and "subcontractor" include, but are not limited to, a
billing service or data transmission service that the provider uses, employs, or contracts with. The
provider agrees further that it shall be liable for any and all breaches of this Agreement that may be
committed by an organizational component to which a Medicare provider number, supplier number,
UPIN, or billing number has been assigned, irrespective of whether such component has, itself,
separately executed an EDI agreement.
2. Not to disclose any information concerning a Medicare patient to any other person or
organization, except HCFA and /or its contractor, without the express written permission of the
• Medicare patient or his/her parent or legal guardian or as required by State or Federal law.
3. To ensure that Medicare patient eligibility data are used only for the purpose of preparing
and filing accurate Medicare claims.
4. To submit claims only on behalf of those Medicare patients who have given their written
authorization to do so, and to certify that required patient signatures, or legally authorized signatures
on behalf of patients, are on file.
5. To ensure that every electronic entry can be readily associated and identified with an
original source document. Each sauce document must reflect the following information:
o Patient's name,
o Patient's health insurance claim number,
o Date(s) of service,
o Diagnosis/nature of illness, and
o Procedure /service performed.
6. That the Secretary of Health and Human Services or his/her designe and /or the
contractor has the right to audit and confirm information submitted by the provider and shall have
access to all original source documents and medical records related to the provider's submissions,
including the patient's authorization and signature. All incorrect payments that are discovered as a
result of such an audit shall be adjusted according to the applicable provisions of the Social Security
• Act, Federal regulations, and HCFA guidelines.
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7. To certify that all claims for Medicare primary payment have been developed for other
• insurance involvement and that medicare is the primary payer.
8. To guarantee the accuracy, completeness, and truthfulness of all claims submitted to the
contractor.
S. To retain all original source documents and medical records pertaining to any such
particular medicare claim for a period of at least 6 years, 3 months after the bill is paid.
10. To prevent unauthorized users from submitting claims or committing other data security
violations.
1 1. To affix the Medicare- assigned number of the provider on each claim electronically
transmitted to the contractor.
12. That the Medicare - assigned number constitutes the provider's legal electronic signature
and constitutes an assurance by the provider that services were performed as billed.
13. To provide and maintain the equipment, software, services and testing necessary to
effectively and reliably transmit claims, and to use other available data services required by HCFA,
such as receipt of remittance advice.
14. To use sufficient security procedures to ensure that all transmissions of documents are
• authorized and protect all patient - specific data from improper access.
15. To acknowledge that all claims will be paid from Federal funds, that the submission of
such claims is a claim for payment under the medicare program, and that anyone who misrepresents
or falsifies or causes to be misrepresented or falsified any record or other information relating to that
claim that is required pursuant to this Agreement may, upon conviction, be subject to a fine and /or
imprisonment under applicable Federal law.
16. If the provider has executed a Medicare provider agreement, or accepted assignment
of the beneficiary's claim, the provider agrees to accept the amount approved by Medicare as full
payment for services on the claim and to bill the patient only for deductible, coinsurance, and
noncovered services to the extent permitted by the Medicare program. If the claim is not accepted
on an assignment- related basis by a provider who is a physician or supplier, but such provider submits
the claim electronically on the beneficiary's behalf, then such provider agrees to limit charges to the
beneficiary, with respect to the item or service furnished to the beneficiary, to a percentage
established by HCFA of the Medicare payment established by HCFA for such item or service.
17. To establish and maintain procedures and controls so that information concerning
Medicare patients, - or any information obtained from HCFA or its contractor, shall not be used by
agents, officers, or employees of the billing service excepts as provided by the contractor (in
accordance with 1106 (a) of the Act).
1 S. To research and correct any and all claim discrepancies and to hold the contractor and
• HCFA harmless from any claims, cost, or damages incurred as a result of such discrepancies.
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B. The Health Care Financina Administration Agrees:
1. To transmit to the provider an acknowledgement of claim receipt.
• 2. To affix the intermediary /carrier number, as its electronic signature, on each
remittance advice sent to the provider.
3. To ensure that payments to providers are timely in accordance with HCFA's
policies.
4. That no contractor may require the provider to purchase any or all electronic
services from the contractor or from any subsidiary of the contractor or from any company for which
the contractor has an interest. The contractor will make alternative means available to any electronic
biller to obtain such services.
5. To keep providers apprised at all times of HCFA's regulations and guidelines
pertinent to EMC. All submitters must receive the information in an equally timely manner.
6. To ensure that all Medicare electronic billers have equal access to any services
HCFA requires Medicare contractors to make available to providers or their billing services, regardless
of the electronic billing technique or service they choose. Equal access will be granted to any services
the contractor sells directly, indirectly, or by arrangement.
C. The Parties Mutually Aaree That:
If any transmitted data are received in an unintelligible or garbled form, the receiving party, if feasible,
• shall notify the originating party within 2 business days.
This Agreement shall become effective when executed by both of the parties. The responsibilities and
obligations contained in this document will remain in effect as long as medicare claims are submitted
to the contractor. Either party may terminate the Agreement by giving the other party thirty (30) days
written notice of its intent to terminate. Written notice will be deemed received on the date it is
handed to the other party or the date it is postmarked if the mail is used.
•
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D. Signatures:
I am authorized to enter into this Agreement on behalf of the indicated party and I have read and
• agree to the foregoing provisions and acknowledge same by signing below.
Provider's Name For HCFA:
VILLAGE OF TEQUESTA FIRE RESCUE Scott A. Masters
_ Manager - EMC /ACS Su000rt
357 TEQUESTA DRIVE (P.O. BOX #3273) Title
_ 532 Riverside Avenue - 6C
Address Address -
T EQUESTA, FL 33469 -0273 Jacksonville. Florida 32202 -4918
City /State /Zip City /State /zip
By 44 B
THOMAS G. BRADFORD
Title VILLAGE MANAGER Title
Date j ! , Date
• PLEASE PROVIDE THE FOLLOWING MEDICARE INFORMATION
Physician /Supplier /PA Group Signature
Current Sender Number: K 17 9 2
e lf physician, supplier, PA group previously filed electronically, please indicate sender number which
is/was used: N/A
Type of Claim: ❑ Medicare Part A
® Medicare Part B
Medicare B Physician /Supplier/PA Group Provider Number: A0704
Medicare A 4 digit Provider Number: 10 _ _ _ _
PA Groups should complete the reverse side.
•
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For PA Groups Only:
• To expedite the processing of your agreement, please provide the name, signature, provider number,
and date of all physicians billing under this PA Group.
Physician's
Provider
Name (Signature) Name (Printed) Number Da e
Aq
• EDI 2/25/94