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Home My Public Portal About059-2017 - Fire - State -OMPP - 2014 Governmental Ambulance Payment AdjustmentAGREEMENT BET)NBEN THE CITY OF RICHMOND FIRE DEPARTMENT AND THE STATE OF INDIANA FOR ITS 2014 GOVERNMENTAL AMBULANCE PAYMENT ADJUSTMENT FOR MANAGED CARE SERVICES This Agreement is entered into by The City of Richmond Fire Department of Wayne County, Indiana ("Provider"), a governmental ambulance provider, and the State of Indiana, through the Family and Social Services Administration, Office of Medicaid Policy and Planning ("OMPP" or "the State"). This Agreement is an amendment to the Indiana Health Coverage Programs (IHCP) Provider Agreement for The City of Richmond Fire Department. WHEREAS, in June 2017 the Provider will Snake a permissible intergovernmental tinnsfer (IGT) of funds in order to fund the Fiscal Year 2014 Governmental Ambulance Payment Adjustment for managed care services (the "Payments"). The Payments will be paid to Provider in 2017 by the state's contracted managed care entities; and WHEREAS, the Provider and the State recognize that the Centers for Medicare & Medicaid Services ("CMS") has the authority to determine whether the Payments are Medicaid expenditures of funds which are eligible for federal financial participation ("FFP"); NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, it is hereby agreed as follows: 1. The Provider will make an IGT of funds via check in the amount of Twenty -Eight Thousand Four Hundred Thirty -Seven Dollars and Ten Cents ($28,437.10), which are not federal funds, or are federal funds authorized by federal law to match other federal funds. 2. The State's Payment to the Provider will be made by the state's contracted managed care entities in the amount of Eighty -Five Thousand Tyro Hundred Thirty Dollars and Eighty -One Cents ($85,230.81), the total amount. 3. The Provider will retain one hundred percent (100%) of the Payment described in Paragraph 2, above. 4. In the event that the State is notified by CMS that FFP will not be recognized, CMS defers the State's claim for FFP, or CMS issues a notice of disallowance, the Provider shall do the following: (a) If CMS defers the State's claim for FFP for any reason, the Provider shall provide to the State any and all information requested by CMS to support the claim and resolve the deferral. The parties agree that the State has no responsibility, other than to submit information to CMS that is provided by the Provider, to attempt to resolve the deferral in favor of the Provider. (b) If CMS issues a notice of disallowance, the Provider shall, within fifteen (15) calendar days after notification by the State that CMS has declined to approve the Payments for purposes of FFP eligibility: deliver to the State funds in the amount of Eighty -Five Thousand Two Hundred Thirty Dollars and Eighty - One Cents ($85,230.81). Such payment shall be the amount of the Provider's ambulance payment adjustment described in Paragraph 2, above. (c) The Provider shall waive any appeal based on the CMS determination to disallow FFP for the Provider's Payments. Such waiver shall include any demands of payment or offset against claims by the State. Contract No. 59-2017 5. In the event the State is notified by CMS that FFP will not be recognized for the Payment, the State shall, within fifteen (15) calendar days after notification that CMS has declined to approve the Payment as eligible for FFP, deliver to the Provider funds in the amount of i'wenty-Eight Thousand Four Hundred Thirty -Seven Dollars and Ten Cents ($28,437.10). Such payment represents the Provider's IGT made in the form of a check as described in Paragraph 1, above. In the event that the State fails to make this payment in full during the fifteen (15) day period specified, the Provider shall be entitled to immediately pursue any and all recoupment efforts against OMPP. 6. This Agreement cannot be amended, modified, or supplemented in any respect except by subsequent written agreement signed by the parties. 7. This Agreement shall be governed by the laws of the State of Indiana. 8. This Agreement shall be binding upon the parties hereto, and their personal representatives, heirs, assigns, and successors in interest. IN WITNESS WHEREOF, the Provider and the State, by their duly authorized officers or agents, have executed this Agreement. THE CITY OF RICHMOND FIRE DEPARTMENT: Jerry L. Purcell Chief Date: c3 Z(o 20171 THE STATE OF INDIANA: Allison Taylor Interim Medicaid Director, Family and Social Services Administration Date: VENDER NO. 04412 CHECK DATE 06/02/2017 57162 2014 MEDICAID 05/24/17CONTRACT #59-2017, 28437.10 1 0.00 28437.10 TREASURER OF THE STATE OF INDIANA 28437.10 0.00 I28437.10 ul00000 5 7 L 6 21i' 1:0 740000 LOI: 70 749 28 L 511' CITY OF RICID40ND FIRE DEPARTMENT - 101 SOUTH FIFTH STREET-RICHMOND, INDIANA 47374 PHONE (765) 983-7266 — FAX (765) 962-1808 E-mail iDurcell('a).riclimondindiana.eov E-mail: tbrovtim0 ichmondindiana.eov May 23, 2017 Myers & Stauffer, LC Attn: Berry Bingaman 9265 Counselors Row, Suite 100 Indianapolis, IN 46240 Provider Name: Richmond Fire Department Provider Address: 101 South 5th Street Richmond, IN 47374 Provider Number. 201063800 A Federal Tax ID Number: 35-6001174 DAVE SNOW Mayor JERRY L. PURCELL Fire Chief TIMOTHY R. BROWN Assistant Fire Chief Dear Sir or Madam: The Richmond Fire Department has received the Indiana Medicaid Managed Care Governmental Ambulance Payment Adjustment Notice of Program Reimbursement for Medicaid Managed Care Ambulance Services provided for the fiscal year ended December 31, 2014. By virtue of this letter, Richmond Fire Department accepts the proposed settlement, waives the rights to appeal and would like to proceed with finalizing this determination and the issuance of the Indiana Medicaid Managed Care Governmental Ambulance Adjustment Payment. Please find attached the following documents: Notice of Program Reimbursement Payment Letter from Myers and Stauffer Signed Payment Agreement A check in the amount of twenty eight thousand four hundred thirty seven dollars and ten cents ($28,437.10) made payable to the Treasurer of the State of Indiana Please contact me at (765) 983-7264 if you need any additional information. Sincerely, Jerry Purcell Chief Richmond Fire Dep nt C: Lisa Rooney �Oy May 23, 2017 Jerry L. Purcell Chief City of Richmond Fire Department 101 S. 5th Street Richmond, IN 47374 Eric Holcomb, Governor State of Indiana Irxdiana Health Coverage Prograrrts %~.indianamedicaid.com MYERS AND STAUFFER LC 9265 COUNSELORS ROW, SUITE 100 INDIANAPOLIS, IN 46240 800.877.6927 1317.846.9521 www.msic.com/Indiana RE: 2014 Governmental Ambulance Payment Adjustment for Managed Care Services UPS Tracking Number— 1Z 9V1 W32 03 9234 2203 Provider Name: City of Richmond Fire Department Provider Number: 201063800A NOTICE OF PROGRAM REIMBURSEMENT ram Reimbursement This fetter i' the i Indiana MedOffice of iedicaid caid Governmental Ambulaicy and nce Payment Adice of justment stment for Medicaid managed your facility's care ambulance services for calendar year 2014. This payment adjustment was calculated based on your facility's submitted cost report for fiscal year ended December 31, 2014 and Medicaid managed care claims for services incurred during calendar year 2014. FINAL ORDER The Indiana Medicaid Governmental Ambulance Payment Adjustment for Medicaid managed care ambulance services for calendar year 2014 is $85,230.81. The intergovernmental transfer (IGT) amount is $28,437.10. If you are in agreement with this payment, upon receipt of this letter, please submit the following information to the address below no later than fifteen (15) days of your receipt of this letter: a cover letter, a copy of this payment letter, the signed Payment Agreement (enclosed with this letter), and the intergovernmental transfer check in the amount of $28,437.10 made payable to the Treasurer of the State of Indi&na. We recommend submitting these documents in a manner through which delivery can be confirmed, such as hand delivery, courier, United States Post Service certified mail, United Parcel Service, or Federal Express. Indiana Family and Social Services Administration 13992 Collections Center Drive Chicago, IL 60693 f''E. siaiE 4 Children's Health Insurance Program • Healthy Indiana Plan . Hoosier Care Connect Hoosier Healthwise - M.E.D. Works • Traditional Medicaid `. WR � r . City -of Richmond Fire Department May 23, 2017 Page 2 of 2 The cover letter must include your facility's name and address and your federal tax identification number. You will receive your Indiana Medicaid Governmental Ambulance Payment Adjustment for managed care services for calendar year 2014 after this information has been received. APPEAL SECTION This notification constitutes an appealable order. If you disagree with this determination, you have the right to appeal under 405 IAC 1-1.5. In order to assert your appeal rights, you must file an appeal request within fifteen (15) days of your receipt of this letter. The appeal request must state that you are the party to whom the order is specifically directed; that you are adversely affected by the determination; and that you are entitled to review under the law. Please refer to the rule for further information on your appeal rights. Appeals should be sent to the following address: Jennifer Walthall, M.D, MPH, Secretary MS07-Office of Medicaid Policy and Planning ATTN: Mr. Chris Fletcher 402 West Washington Room W382 Indianapolis, IN 46204 A copy of this notice must accompany your appeal request. A copy of the appeal should also be sent to Myers and Stauffer LC at the address listed below. Failure to file an appeal request within fifteen (15) days from receipt of this letter will result in the waiver of any right to appeal this determination. If you elect to appeal this dater urination, you must also file a statement of issues within (45) days after you receive notice of this determination. The statement of issues should be sent to the same address as the appeal request. The statement of issues should conform to 405 IAC 1-1.5-2 (e). The statement of issues and the appeal request may be filed together. Please also forward a copy of the statement of issues to Myers and Stauffer LC at the following address: Myers and Stauffer LC Attn: Berry Bingaman 9265 Counselors Row, Suite 100 Indianapolis, IN 46240 If you elect to waive your right to an appeal, please fax or mail such notification to Berry Bingaman, in care of Myers and Stauffer LC. The fax telephone number is (317) 571-8481. Sincerely, Berry Bingaman, CPA Myers and Stauffer LC cc: Jennifer White, OMPP Enclosure