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Deschutes County Board of Commissioners
1300 NW Wall St., Suite 200, Bend, OR 97701-1960
(541) 388-6570 - Fax (541) 385-3202 - www.deschutes.org
AGENDA REQUEST & STAFF REPORT
For Board Business Meeting of September 24, 2008
Please see directions for completing this document on the next page.
DATE: September 26, 2008
FROM: Sheryl Hogan Mental Health 541-322-7571
TITLE OF AGENDA ITEM:
Consideration of Board Signature of Document No. 2008-511, an Agreement with Jefferson Behavioral
Health for Mental Health Services for Clients in or near Southern Deschutes County
PUBLIC HEARING ON THIS DATE? No
BACKGROUND AND POLICY IMPLICATIONS:
Gilchrist and Crescent area residents in need of mental health services often have to go to Klamath Falls
for treatment. This distance creates a barrier to receiving needed mental health treatment. With the
Jefferson Behavioral Health (JBH) contract, Deschutes County Mental Health (DCMH) will provida
and receive funding for the provision of medically necessary mental health services to JBH clients that
reside in or near Deschutes County.
FISCAL IMPLICATIONS:
In the past, DCMH was unable to obtain payment for providing mental health services to JBH clients.
This contract will allow DCMH to obtain authorization and payment for services provided to eligible
JBH clients. At this time, approximately seven (7) clients served by DCMH meet eligibility criteria.
Historically, this number increases during the school year as Klamath County children in LaPine
Schools need school-based mental health services. The total financial impact of serving eligible
Klamath County clients is unknown at this time. During the course of the two year contract, we
estimate that DCMH will receive a minimum of $20,000. for these services. this estimate has been
incorporated into the DCMH budget.
RECOMMENDATION & ACTION REQUESTED:
Board signature of Document No. 2008-511.
ATTENDANCE: Sheryl Hogan
DISTRIBUTION OF DOCUMENTS:
Please return two signed originals to Sheryl Hogan at Mental Health for distribution.
February'
541 -322 -
DESCHUTES COUNTY DOCUMENT SUMMARY
(NOTE: This form is required to be submitted with ALL contracts and other agreements, regardless of whether the document is to be
on a Board agenda or can be signed by the County Administrator or Department Director. If the document is to be on a Board
agenda, the Agenda Request Form is also required. If this form is not included with the document, the document will be returned to
the Department. Please submit documents to the Board Secretary for tracking purposes, and not directly to Legal Counsel, the
County Administrator or the Commissioners. In addition to submitting this form with your documents, please submit this form
electronically to the Board Secretary.)
Date:
Please complete all sections above the Official Review line.
September 5, 2008
Contact Person:
Patty Terhune
Contractor/Supplier/Consultant Name:
Department:
Mental Health
Phone #:
541-244-4860
Deschutes County Mental Health
Goods and/or Services: Deschutes County Mental Health (DCMH) will provide
medically necessary mental health services to Jefferson Behavioral Health (JBH) clients
that reside in or near Deschutes County.
Background & History: Gilchrist area residents in need of mental health services
often have to go to Klamath Falls for treatment. This distance creates a barrier to
receiving needed mental health treatment. LaPine Schools serve Gilchrist youth and
have been served by DCMH school-based providers. In the past, DCMH was unable to
obtain payment for providing mental health services to JBH clients. This contract will
allow DCMH to obtain authorization and payment for services provided to eligible JBH
clients.
Agreement Starting Date:
28, 2010
March 1, 2008
Annual Value or Total Payment:
$20,000
Ending Date:
❑ Insurance Certificate Received (check box)
Insurance Expiration Date: not applicable
Check all that apply:
❑ RFP, Solicitation or Bid Process
❑ Informal quotes (<$150K)
® Exempt from RFP, Solicitation or Bid Process (specify — see DCC §2.37)
Funding Source: (Included in current budget? ® Yes ❑ No
If No, has budget amendment been submitted? ® Yes ❑ No
Departmental Contact:
75711
Title:
Sheryl Hogan
Adminstrative Analyst
Department Director Approval:
Phone #:
Date
Distribution of Document: Please return two originals with proof of county self-
insurance to Sheryl Hogan.
9/5/200 3
Official Review:
County Signature Required (check one): C3/BOCC ❑ Department Director (if <$25K)
❑ Administrator (if >$25K but <$150K1; if >$150K, BOCC Order No.
Legal Review
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Document Number 2008-511
9/5/200,
PERSONAL SERVICES CONTRACT
This Agreement (the "Agreement") is made and entered into by and between,
Deschutes County and its Community Mental Health Program (hereinafter called
"CONTRACTOR") and JEFFERSON BEHAVIORAL HEALTH ("JBH"), which is
comprised of JBH and its member counties (Coos, Curry, Douglas, Jackson, Josephine,
and Klamath Counties) with reference to the following facts:
RECITALS
JBH is an Oregon ORS Chapter 190 Intergovernmental Entity that has as its primary
objective to arrange for and facilitate the provision and delivery of Mental Health
Services to persons enrolled in the Oregon Health Plan and assigned to JBH or who are
covered by intergovernmental agreements with JBH ("Member").
CONTRACTOR is and its designated Community Mental Health Program ("CMHP") is
required to provide comprehensive mental health services to DMAP Members under
this Contract.
CONTRACTOR and JBH desire to enter into this Agreement
NOW, THEREFORE, the parties hereby agree as follows:
1.0 DEFINITIONS
For purposes of this Agreement, the following terms shall have the meanings indicated
below:
A. Case Management and Utilization Review Program — the procedures and
standards established and administered by JBH to ensure that the Mental
Health Services provided to Members are Medically Necessary and
appropriate.
B. Co -payment — are charges in addition to those charges paid by JBH that
may be directly assessed against the Member by CONTRACTOR at the
time of the provision of certain Mental Health Services if co -payments are
a feature of Member's mental health benefit. All co -payments are
deducted from CONTRACTOR'S contracted fees with JBH.
C. Covered Services — are Medically Necessary Mental Health Services
provided to an eligible Member as part of a Health Plan pursuant to this
Agreement for which CONTRACTOR is qualified to provide and accepts
payment from Payor as payment in full, except for applicable Co-
payments.
D. Critical Incidents - include physical injury to consumer, death, suicide
attempt, abuse by CONTRACTOR or CONTRACTOR'S staff, serious
property damage, threats to the safety of others, and other incidents of a
similarly serious nature. REVIE
Page 1 of 17
Deschutes County / JBH Personal Services Contract f
LEGAL COUNSEL
E. Deductible — is the amount, if any, a Member must pay before a Health
Plan begins paying for Mental Health Services.
F. Health Plan(s) — are Mental Health Services benefit plan(s) through which
JBH is responsible for the provision of Behavioral Health Services to
Members, including, but not limited to the Oregon Health Plan.
G. Medically Necessary Services — an intervention recommended by the
treating practitioner that is:
a. A behavioral health intervention for the purpose of treating a mental
health condition;
b. Delivered at an appropriate level of service, considering potential
benefits and harm to the Member;
c. Known to be effective in treating the mental health condition.
H. Member — is an individual who is enrolled in the Oregon Health Plan and
assigned to JBH and who meets all the eligibility requirements for
membership in such plan.
I. Mental Disorder — is a mental or nervous condition diagnosed by a
Practitioner according to the criteria in the most current version of the
Diagnostic and Statistical Manual of Mental Disorders (DSM).
J. Mental Health Practitioner — is the supervising psychiatrist, psychologist or
other allied behavioral health professional who is qualified and duly
licensed or certified under the laws of the State of Oregon.
K. Outpatient Mental Health Services — are Mental Health Services provided
for the treatment of Mental Disorders in an outpatient setting by a mental
health practitioner.
L. OHP — Oregon Health Plan: The OHP is the managed care plan for
providing Medicaid services to covered members in Oregon.
M. Payment Amounts — are those monies payable to CONTRACTOR
pursuant to Paragraph 4 of this Agreement as compensation for Mental
Health Services provided to Members.
N. Provider Manual — is a manual provided by JBH to CONTRACTOR setting
forth the administrative and operational procedures relating to the
performance of this Agreement, including those involving levels of care,
case management, quality assurance and utilization review programs. The
JBH Quality Management and Utilization Management Plans are
incorporated by reference into this agreement.
O. UM —Utilization Management: process of reviewing and authorizing
medically necessary services.
Deschutes County / JBH Personal Services Contract Page 2 of 17
2.0 TERM OF CONTRACT. This contract shall become effective on March 1, 2008
and shall have a term of two (2) years unless terminated sooner pursuant to the
terms of Section 13.
3.0 SERVICES TO BE PROVIDED. CONTRACTOR shall provide outpatient mental
health services for Oregon Health Plan members, herein called Members, of JBH
as outlined in Attachment A "Outpatient/ICTS Mental Health Services and
Service Requirements" and Attachment C "BRS Services, Fee Schedule, and
Service Requirements.
4.0 INVOICING/BILLING
A. Payment will be made only for actual expenditures up to the maximum
amount(s) specified in the fee schedule listed in Attachment(s) B. The
CONTRACTOR will use best efforts to submit detailed billings to JBH
through JBH's third party administrator.
B. CONTRACTOR may submit claims by using the CMS 1500 form in
accordance with HIPAA regulations. CONTRACTOR must submit claims
to JBH's Third Party Administrator no later than thirty (30) days following
the date of health care service delivery. Failure to submit billings within
this time period will result in denial of payment. Such billings shall include
all information required to adjudicate the claim.
C. JBH shall pay for covered services provided to Member within thirty (30)
days after receipt by JBH or JBH's Third Party Administrator of a
completed "clean" claim. A claim shall be considered "complete' and
"clean" when submitted in the format consistent with the previous
paragraph, containing all necessary data elements, and with all requested
supporting documentation, including a valid authorization.
D. JBH will report the total amount of all payments to CONTRACTOR,
including any expenses, in accordance with Federal Internal Revenue
Service and State of Oregon Department of Revenue regulations.
CONTRACTOR shall be responsible for any Federal or State taxes
applicable to amounts paid under this contract.
5.0 COLLECTION OF CHARGES FROM MEMBERS. With the exception of non -
covered services, CONTRACTOR shall in no event, including but not limited to,
insolvency of JBH, or breach of the Agreement, bill, charge, collect a deposit, or
attempt to bill, charge, collect or receive any form of payment from any Member
for Mental Health Services provided pursuant to this Agreement other than co-
payments, deductibles, or other charges required and specified by the Division of
Medical Assistance Programs (DMAP) under the Oregon Health Plan.
CONTRACTOR shall not maintain any action at law or equity against a Member
to collect sums owed by JBH to CONTRACTOR. Upon notice of any such action
or charge, JBH may terminate this Agreement and take all other appropriate
action consistent with the terms of this Agreement (Section 13) to eliminate such
charges, including requiring CONTRACTOR to return all sums collected by
Deschutes County / JBH Personal Services Contract Page 3 of 17
CONTRACTOR as surcharges from Members or their representatives. Nothing
in this Agreement, however, shall be construed to prevent CONTRACTOR from
providing non -covered health care services on a usual and customary fee-for-
service basis to Members.
CONTRACTOR'S obligations under this Section shall survive the termination of
this Agreement with respect to mental health services provided during the term of
the Agreement without regard to cause of termination of the Agreement.
6.0 COLLECTION OF CHARGES FROM THIRD PARTIES. CONTRACTOR accepts
payment from JBH for mental health services provided herein as full payment for
such services; however, in the event of third party liability, worker's
compensation claims, or other primary insurance coverage maintained by
Member, CONTRACTOR shall be entitled to all reimbursement received from
such primary sources of payment for all mental health services. Such payment is
considered primary to any payment obligation of JBH and must be billed prior to
billing JBH.
7.0 ASSIGNMENT, DELEGATION, AND SUBCONTRACTING. Neither party shall
assign, subcontract, sublet or transfer any interest in or duty under this
agreement without the written consent of the other, and no assignment shall be
of any force or effect whatsoever unless and until the other party has so
consented.
8.0 STATUS OF CONTRACTOR. The parties intend that CONTRACTOR, in
performing the services specified in this agreement, shall act as an independent
contractor and shall have the control of the work and the manner in which it is
performed. CONTRACTOR is not to be considered an agent or employee of
JBH and is not entitled to participate in any pension plan, insurance, bonus, or
other benefits JBH provides its employees.
9.0 INDEMNIFICATION. JBH has relied upon the professional ability and training of
CONTRACTOR as a material inducement to enter into this agreement.
CONTRACTOR warrants that its work will be performed in accordance with
generally accepted professional practices and standards as well as the
requirements of applicable federal, state and local laws, it being understood that
acceptance of CONTRACTOR's work by JBH shall not operate as a waiver or
release.
CONTRACTOR shall defend, save, hold harmless, indemnify JBH, its officers,
agents and members, from all claims, suits, or actions, of whatever nature
resulting from or arising out of the activities of CONTRACTOR or its officers,
employees, subcontractors, or agents under this contract. This indemnification,
defense and hold harmless shall include attorney's fees and witness costs that
arise in preparation for or in the course of an administrative process, trial or
appeal, whether or not a hearing, trial, or appeal ever takes place. Such
indemnification shall include claims brought against either party under state or
federal workers compensation laws. If any aspect of this indemnity shall be
found to be illegal or invalid for any reason, such illegality or invalidity shall not
Deschutes County / JBH Personal Services Cortract Page 4 of 17
affect the validity of the remainder of this indemnification, and CONTRACTOR
shall indemnify, defend and hold the other harmless to the extent
allowed. Notwithstanding the above, CONTRACTOR shall have no duty to
indemnify, defend or hold harmless JBH for liability, actions, claims, losses,
damages, or other costs that are asserted or arise solely from the negligence of
JBH.
10.0 INSURANCE. CONTRACTOR shall purchase and maintain, at
CONTRACTOR's expense, insurance covering the CONTRACTOR. Coverage
must include:
A. Commercial general liability insurance covering personal injury and
property damage with a combined single limit, or the equivalent of not less
than $1,000,000. This insurance shall include contractual liability
coverage for the indemnity provided under this agreement. The
CONTRACTOR"S policy must specifically include coverage for sexual
abuse and molestation. The coverage for sexual abuse and molestation
will have a $250,000 each occurrence, $500,000 aggregate limit.
Evidence of the inclusion of sexual abuse and molestation coverage and
the limits of that coverage, in the form of an insurance certificate, must be
provided to JBH prior to the execution of an agreement.
CONTRACTOR will be required to certify that they have performed
criminal background checks for any employees, volunteers, or other
representatives who will have contact with clients. This policy shall
provide that JBH; its officers and employees; are named as Additional
Insureds, but only with respect to the work performed under this contract.
B. Professional Liability Insurance with a combined single limit of not Tess
than $1,000,000 each claim, incident or occurrence. This is to cover
damages caused by error, omission or negligent acts related to the
professional services to be provided under this contract.
C. Worker's Compensation Insurance in compliance with ORS 656.017,
which requires subject employers to provide workers compensation
coverage for all their subject workers.
A copy of the policy or Certificate of Insurance acceptable to JBH shall be filed
with the JBH prior to the effective date of this contract. The policy or certificate
shall provide for thirty days notice of cancellation or material change.
CONTRACTOR may fulfill its obligations set forth in this section through a
program of self insurance; provided that CONTRACTOR's self-insurance
program complies with all applicable laws, and provides insurance coverage
equivalent in both type and level of coverage to that specified in this section 10.
Deschutes County / JBH Personal Services Contract Page 5 of 17
11.0 METHOD AND PLACE OF GIVING NOTICE, SUBMITTING BILLS AND
MAKING PAYMENTS. All notices, bills and payments shall be made in writing
and may be given by personal delivery or by mail. Notices, bills, and payments
sent by mail should be addressed as follows
Contractor: Deschutes County Mental Health Phone: (541) 322-7500
2577 NE Courtney Drive
Bend, OR 97701
JBH:
JBH
CLAIMS
Jefferson Behavioral Health
900 SE 8th Street, Suite 100
Grants Pass, OR 97526
Attn: Patty Terhune
JBH Claims
PO Box 5308
Salem, OR 97304
(541) 244-4860 (Main Phone)
(541) 955-8290 (Fax)
Claims Fax: (503) 584-425'I
For assistance call:
(800) 478-2818
(503) 566-9801
And when so addressed, shall be deemed given upon deposit in the United
States mail, postage prepaid. In all other instances, notices, bills, and payments
shall be deemed given at the time of actual delivery. Changes in contact
information are to be given by providing notice pursuant to this paragraph.
12.0 MERGER. This agreement replaces any and all other agreements, whether oral
or in writing, between the parties concerning the services listed in Section 3.0
and contains all of the covenants and agreements between them concerning
these services. No modification of this agreement shall be effective unless and
until it is made in writing and signed by both parties.
13.0 TERMINATION.
A. Termination of this Agreement without Cause. Either Party may terminate
this Agreement without cause at any time by providing ninety (90) days
prior written notice of termination to the other Party. If JBH terminates
the contract pursuant to this paragraph, it shall pay CONTRACTOR for
services rendered up to and including the date of termination.
B. Termination with Cause. Either party may terminate this Agreement with
cause by providing thirty (30) days prior written notice of termination to the
other party. Such notice of termination shall state the circumstances
constituting cause for termination.
1. JBH's Right to Termination. The following shall constitute cause for
termination of this Agreement by JBH:
a. CONTRACTOR's failure to provide Behavioral Health Services
in accordance with the standards set forth in JBH's Provider
Manual currently in effect, and CONTRACTOR's subsequent
Deschutes County / JBH Personal Services Cortract Page 6 of 17
failure to correct such deficiencies within thirty (30) days after
receipt of written notice by JBH of such deficiencies.
b. CONTRACTOR's breach of any other material term or condition
of this Agreement and subsequent failure to cure such breach, if
curable, within thirty (30) days after receipt of written notice by
JBH of such breach. The remedy of such breach within the
thirty (30) day period shall revive this Agreement for the
remaining term, subject to any of the rights of termination
contained in any other provision of this Agreement.
2. CONTRACTOR's Right to Termination. The following shall
constitute cause for termination of this Agreement by
CONTRACTOR:
a. JBH's failure to make compensation payments due to
CONTRACTOR, and JBH's subsequent failure to cure such
non-payment within thirty (30) days after receipt of written notice
by CONTRACTOR of such non-payment.
b. JBH's breach of any other material term or condition of this
Agreement and subsequent failure to cure such breach, if
curable, within thirty (30) days after receipt of written notice by
CONTRACTOR of such breach. The remedy of such breach
within the thirty (30) day period shall revive this Agreement for
the remaining term, subject to any of the rights of termination
contained in any other provision of this Agreement.
14.0 NON-DISCRIMINATION IN TREATMENT OF CONSUMERS BY
CONTRACTOR. CONTRACTOR shall not discriminate against Members in
violation of any local, state or federal law with respect to care and shall provide
services to Members in the same manner, in accordance with the same
standards and within the same time availability as those services are provided to
CONTRACTOR's other clients. CONTRACTOR shall not discriminate in the care
or quality of services on the basis of race, religion, color, sex, marital status,
familial status, national origin, age, mental or physical disability, sexual
orientation, source of income, or political affiliation.
15.0 COMPLIANCE WITH APPLICABLE LAWS AND LICENSES. CONTRACTOR
shall comply with all applicable federal, state or local laws, rules and regulations
applicable to the work performed under this Agreement. CONTRACTOR shall
comply with all applicable standards of professional ethics and shall perform
services within the scope of CONTRACTOR's licenses.
ORS Chapter 279A, 279B, and 279C Required Provisions: JBH has determined
that this contract is a personal services contract for medical services of the
Contractor performing work under this contract, is exempt from the wage, hour
and overtime requirements of ORS 279A, 279B, and 279C for purposes of this
contract. All other provisions required to be included in public contracts by these
statutes are incorporated by this reference and made a part of this agreement.
Deschutes County / JBH Personal Services Cortract Page 7 of 17
16.0 CREDENTIALING:
A. JBH shall credential CONTRACTOR in accordance with JBH's
Credentialing and Re-Credentialing Policy and Procedures.
B. CONTRACTOR shall credential its employees and any provider
responsible for direct clinical services as described in OAR 401-141-0120,
Oregon Health Plan Prepaid Health Plan Provision of Health Care
Services.
C. Payment shall be denied for any service delivered by any provider not
credentialed in accordance with JBH's Credentialing and Re-Credentialing
Policy and Procedures. Only credentialed, authorized providers may
provide service to JBH members.
17.0 CONFIDENTIALITY AND HIPAA PROVISIONS.
CONTRACTOR agrees to hold all individually identifiable patient health
information ("Protected Health Information") that may be shared, transferred,
transmitted, or otherwise obtained pursuant to this Agreement strictly
confidential, and provide all reasonable protections to prevent the unauthorized
use or disclosure of such information, including, but not limited to the protection
afforded by applicable federal, state and local laws and/or regulations regarding
the security and the confidentiality of patient health care information. Provider
further agrees to make every reasonable effort to comply with any regulations,
standards, or rules promulgated pursuant to the authority of the Health Insurance
Portability and Accountability Act of 1996 ("HIPAA"), including those provisions
listed below, as soon as possible, but in no event later than the mandatory
HIPAA compliance date. The Provider may use and disclose Protected Health
Information when necessary for Provider's proper management and
administration (if such use or disclosure is necessary), or to carry out Provider's
specific legal responsibilities pursuant to this Agreement.
18.0 MAINTENANCE OF RECORDS. CONTRACTOR shall maintain and provide
(subject to the provisions of Section 17.0 above) to JBH or any governmental
agency with regulatory authority over CONTRACTOR or JBH, access to all
Member patient records and other information relating to Behavioral Health
Services provided to Members, in such form and containing such information as
required by applicable state law (and in accordance with usual and customary
practices in the United States), including medical and behavioral health histories,
records and reports from other providers, discharge summaries, and such other
information as JBH, or other governmental agency may require. CONTRACTOR
shall maintain such records for the greater of seven (7) years or the length of
time CONTRACTOR is required to maintain patient records under applicable
state law.
19.0 CONFLICT OF INTEREST: CONTRACTOR covenants that it presently has no
interest and shall not acquire any interest, direct or indirect, which would conflict
in any manner or degree with the performance of its services. The
Deschutes County / JBH Personal Services Contract Page 8 of 17
CONTRACTOR further covenants that in the performance of this contract no
person having any such interest shall be employed.
20.0 AUDIT: CONTRACTOR shall maintain records to assure conformance with the
terms and conditions of this agreement, and to assure adequate performance
and accurate expenditures within the contract period. CONTRACTOR agrees to
permit JBH the State of Oregon, the federal government, or their duly authorized
representatives to audit all records pertaining to this agreement to assure the
accurate expenditure of funds.
Nothing in this contract shall hinder or interfere with State or Federal
administration of the Medicaid Program or other State or Federally funded
programs from conducting audits and recovering State and/or Federal funds that
are not expended in compliance with State and/or Federal requirements.
21.0 DISPUTE RESOLUTION. The parties agree that any dispute or claim that arises
out of or relates to this agreement, or to the interpretation or breach of this
agreement, shall be resolved by arbitration in accordance with the then existing
rules of the Arbitration Service of Portland, Inc., and judgment upon the award
rendered to such arbitration may be entered in any court having jurisdiction over
this agreement. The parties acknowledge that mediation usually helps parties
resolve their disputes; therefore, any party may propose mediation whenever
appropriate through any mediation process or mediation the parties may agree
upon.
22.0 VENUE, JURISDICTION AND APPLICABLE LAW. The venue for any action
arising out of or relating to this agreement shall be in Deschutes County, Oregon.
Any court action arising out of or relating to this agreement shall be filed in the
Circuit Court of Curry County, Oregon. The applicable laws for any action arising
out of or relating to this agreement shall be the laws of the State of Oregon.
CONTRACTOR specifically agrees to abide by the provisions of ORS 279,
incorporated by this reference.
23.0 SERVICE INTEGRATION. The CONTRACTOR shall obtain signed releases
and/or authorizations consistent with State and Federal and other applicable
privacy and security standards, including HIPAA, from all JBH referred members
and submit documentation of services provided under this Contract to Member's
Primary Care Physician (PCP) and/or other clinicians providing health services
related to the Member's mental health condition within thirty (30) days of service
for inclusion in the Member's medical record.
24.0 MEMBER ELIGIBILITY. CONTRACTOR must verify Member's eligible status as
a JBH Member at time of each service. JBH shall only provide reimbursement for
members who are enrolled with JBH on the date of service delivery.
25.0 MEMBER NOTICE, GRIEVANCES AND APPEALS. CONTRACTOR shall follow
JBH's policy and procedure for resolution of Mernber's grievances and appeals.
JBH's policies and procedures are incorporated by reference into this agreement.
All grievances must be reported to the appropriate county mental health program
Deschutes County / JBH Personal Services Cortract Page 9 of 17
within 5 working days. JBH policy and procedure on DMAP Member Grievance,
Appeal and Hearing Process is incorporated into this contract by reference.
CONTRACTOR shall follow JBH's policy and procedure for Notice of Action to
Members when CONTRACTOR reduces, denies, or terminates services without
the Member's expressed concurrence. JBH policy and procedure on Written
Notices is incorporated into this contract by reference.
26.0 PARTICIPATION IN QUALITY MANAGEMENT, UTILIZATION REVIEW, AND
PEER REVIEW. CONTRACTOR may participate in such Utilization Review, Peer
Review, and Quality Management programs that JBH, including JBH staff and/or
the county mental health staff of JBH member counties, may deem necessary or
reasonable to contain or reduce medical costs without compromising adequate
mental health treatment.
The JBH Quality Management and Utilization Management Plans are
incorporated by reference into this agreement.
27.0 REFERRALS AND AUTHORIZATIONS:
A. CONTRACTOR will not be reimbursed for any services without receipt of
written authorization from JBH through JBH or one of JBH's member
counties.
B. CONTRACTOR shall only be reimbursed for types and frequency of
service authorized by JBH or JBH's member counties.
28.0 ACCESS TO RECORDS AND FACILITIES. CONTRACTOR shall provide
access to records and facilities as described in OAR 410-141-0180, Oregon
Health Plan Prepaid Health Pian Record Keeping. At all reasonable times,
CONTRACTOR shall provide JBH, its Member Counties, DMAP (Division of
Medical Assistance Programs), the AMH (Addictions and Mental Health), the
Centers for Medicare and Medicaid Services (CMS), the Office of Inspector
General (OIG) of the United States, the office of the Comptroller General of the
United States, the Oregon Secretary of State, and all their duly authorized
representatives the right of access to its facilities. Financial and medical records,
which are directly pertinent to this Agreement, will also be provided by
CONTRACTOR in order to monitor and evaluate cost, performance, compliance,
quality, appropriateness, and timeliness of services provided under this
Agreement and the capacity of CONTRACTOR to bear the risk of potential
financial losses.
Deschutes County / JBH Personal Services Contract Page 10 of 17
29.0 MISCELLANEOUS FEDERAL AND STATE REQUIREMENTS.
A. Th e CONTRACTOR certifies, to the best of its knowledge and belief, that:
1. No federal appropriated funds have been paid or will be paid by or on
behalf of CONTRACTOR, to any person for influencing or attempting to
influence any officer or employee of any agency, a member of Congress,
an officer or employee of Congress, or an employee of a member of
Congress in connection with the awarding of any federal contract, the
making of any federal grant, the making of any federal loan, the entering
into of any cooperative agreement, and the extension, continuation,
renewal, amendment, or modification of any federal contract, grant, loan,
or cooperative agreement.
2. If any funds other than federal appropriated funds have been paid or will
be paid to any person for influencing or attempting to influence an officer
or employee of any agency, a member of Congress, an officer or
employee of Congress, or an employee of Congress in connection with
this federal contract, grant, loan, or cooperative agreement,
CONTRACTOR agrees to complete and submit Standard Form -LLL
"Disclosure Form to Report Lobbying", in accordance with its instructions.
3. CONTRACTOR is solely responsible for all liability arising from a failure
by CONTRACTOR to comply with the terms of this certification.
Additionally, CONTRACTOR promises to indemnify JBH for any damages
suffered by JBH as a result of CONTRACTOR'S failure to comply with the
terms of this certification.
This certification is a material representation of fact upon which reliance was placed
when this transaction was made or entered into. Submission of this certification is a
prerequisite for making or entering into this transaction imposed by Section 1352, Title
31, US Code. Any person who fails to file the required certification shall be subject to a
civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
A. CONTRACTOR shall maintain financial, medical and other records pertinent to
this Agreement. All financial records shall be maintained pursuant to generally
accepted accounting principles and other records shall be maintained to the
extent necessary to clearly reflect actions taken. CONTRACTOR shall retain all
records, other than medical records, for at least 3 years after final payment is
made under this Agreement or by any subcontract and pending matters are
closed. Additionally, if an audit, litigation, or other action involving the records is
started before the end of the three-year period, the records must be retained
until all issues arising out of the action are resolved or until the end of the three-
year period, whichever is later. Medical records are to be maintained for seven
years. Retention of medical records is covered in OAR 410-141-0180, Oregon
Health Pian Prepaid Health Plan Record Keeping.
B. At all reasonable times, CONTRACTOR shall provide DMAP, AMH, the Health
Care Financing Administration, the Comptroller General of the United States, the
Oregon Secretary of State, and all their duly authorized representatives the right
Deschutes County / JBH Personal Services Contract Page 11 of 17
of access to its facilities. Financial and medical records, which are directly
pertinent to this Agreement, will also be provided by CONTRACTOR in order to
monitor and evaluate cost, performance, compliance, quality, appropriateness,
and timeliness of services provided under this Agreement and the capacity of
CONTRACTOR to bear the risk of potential financial losses. These records shall
be made available to JBH staff and/or member counties for the purpose of
making audit, examination, excerpts, and transcriptions. CONTRACTOR shall,
upon request and without charge, provide a suitable work area and copying
capabilities to facilitate such a review or audit.
Subject to the requirements of 41 CFR part 431, Subpart F, CONTRACTOR
shall not use, release or disclose any information concerning an Oregon Health
Plan Member for any purpose not directly connected with the administration of
JBH's or CONTRACTOR'S responsibilities under this Agreement or under Title
XIX of the Social Security Act, except on written consent of the Oregon Health
Plan Member. Release or disclosure of information may be given, if appropriate,
by Member's legally responsible parent or guardian. CONTRACTOR shall
ensure that its agents, employees and officers with access to Member records
understand and comply with this confidentiality provision.
C. CONTRACTOR shall comply with Title VI of the Civil Rights Act of 1964, the Age
Discrimination Act of 1975, Section V of the Rehabilitation Act of 1973, the
Americans with Disabilities Act of 1990 (ADA), and all amendments to those acts
and all regulations promulgated there under. CONTRACTOR shall also comply
with all applicable requirements of state civil rights and rehabilitation statutes and
rules.
D. If the sums payable to CONTRACTOR under this Agreement exceed $100,000,
CONTRACTOR shall comply with all applicable standards, orders or
requirements issued under Clean Air Act (codified at 42 USC 7401 et.seq.),
Federal Water Pollution Control Act, as amended (codified at 33 USC 1251 et.
seq.), Executive Order 11738, and Environmental Protection Agency (EPA)
regulations (40 CFR Part 15), which prohibit the use of facilities included on the
EPA List of Violating Facilities. Any violations shall be reported to JBH, the
Department of Health and Human Services and to the U.S. EPA Assistant
Administrator for Enforcement (EN -329).
CONTRACTOR shall comply with all mandatory standards and policies that
relate to resource conservation and recovery pursuant to the Resource
Conservation and Recovery Act (codified at 42 USC 6962). Section 6002 of that.
Act requires that preference be given in procurement programs to the purchase
of specific products containing recycled materials identified in guidelines
developed by the Environmental Protection Agency. Current guidelines are
contained in 40 CFR Parts 247-253.
If the sums payable to CONTRACTOR exceed $10,000, CONTRACTOR shall
comply with Executive Order 11246, entitled "Equal Employment Opportunity", as
amended by Executive Order 11375, and as supplemented in Department of
Labor regulations (41 CFR Part 60).
Deschutes County / JBH Personal Services Cortract Page 12 of 17
CONTRACTOR and any laboratories used by CONTRACTOR shall comply with
the Clinical Laboratory Improvement Amendments (CLIA 1988) which require
that:
All laboratory -testing sites providing services under this contract shall
have either a Clinical Laboratory Improvement Amendments (CLIA)
certificate of waiver or a certificate of registration along with a CLIA
identification number. Those laboratories with certificates of waiver will
provide only the eight types of tests permitted under the terms of their
waiver. Laboratories with certificates of registration may perform a full
range of laboratory tests.
E. CONTRACT OR shall comply with the requirements of 42 CFR Part 489, Subpart
I OBRA 1990, Patient Self -Determination Act, and Oregon Revised Statute 127
as amended by the Oregon Legislative Assembly 1993, pertaining to advance
directives.
F. CONTRACTOR will have a written policy and procedure for investigation of
Critical Incidents. CONTRACTOR shall comply with requirements in OAR for
mandatory reporting of abuse for mentally ill or developmentally disabled
individuals as required by ORS 430.735 through 430.765, and 179.040 and OAR
407-045-0250 through 407-045-0350, Abuse Reporting and Protective Services
in Community Programs and Community Facilities and cooperate with any
designee of the Oregon State Department of Human services designated to
investigate abuse under OAR 407-045-0270.
G. CONTRACTOR shall comply with all applicable state and federal laws.
IN WITNESS WHEREOF, the parties hereto have caused this instrument to be
executed in two (2) duplicate originals by their officers, thereunto duly authorized.
DATED this day of , 2008
Deschutes County Jefferson Behavioral Health
Authorize ntract Representative Dave Bast, Executive Director
Date Date
Deschutes County / JBH Personal Services Contract Page 13 of 17
DATED this day of 2008 for the
Deschutes County Board of Commissioners.
DENNIS R. LUKE, Chair
TAMMY (BANEY) MELTON, Commissioner
MICHAEL M. DALY, Commissioner
ATTEST:
Recording Secretary
Attachment A
Outpatient/ICTS Mental Health Services and Service Requirements
CONTRACTOR agrees to provide OHP Plus and OHP Standard Benefit Package of
Covered Services to DMAP Members as described in OAR 410-141-0120, Oregon
Health Plan Prepaid Health Plan Provision of Health Care Services; OAR 410-141-
0520, Prioritized List of Health Services; and OAR 410-141-0480, Oregon Health
Plan Benefit Package of Covered Services. Covered Services shall be sufficient in
amount, duration, or scope to reasonably be expected to achieve the purpose for
which the Services are provided. CONTRACTOR shall ensure that the Services
offered are in an amount, duration, and scope that is no Tess than that furnished to
DMAP clients under fee -or -service. CONTRACTOR may cover, for DMAP
Members, Services that are in addition to those covered under the State plan.
A. Covered Services shall include :
1. Outpatient Mental Health services that are consumer focused and
evidenced based. Services for children and adolescents will be family
centered.
2. Other services that will meet the outpatient mental health needs of DMAP
members.
3. Case management and service coordination.
4. Mental Health Services for children or adolescent DMAP members in ICTS
level of care.
B. Authorizations: All outpatient mental health services must be authorized.
CONTRACTOR must be in receipt of written authorization to ensure
reimbursement for services rendered. Written authorizations must be provided
by JBH.
C. Fees: CONTRACTOR shall be paid in accordance with the Fee Schedule as described
in Attachment B.
D. Claims Submissions: CONTRACTOR must submit claims to JBH's Third Party
Administrator no later than thirty (30) days following the date of health care
service delivery.
E. Record Requirements: CONTRACTOR shall comply with the following records
requirements:
1. Clinical documentation will be completed for each Member served under this
contract and comply with applicable OAR's.
Deschutes County / JBH Personal Services Cortract Page 14 of 1'
Attachment B
Fee Schedule
CODE
JBH FEE FOR SERVICE REIMBURSEMENT RATES
DESCRIPTION
REIMBURSEMENT
EFFECTIVE 04101107
INSIGHT
INTERACTIVE
Diagnostic Intake/evaluation
90801
90801
90801
90801
90802
90802
90802
90802
Board Certified/Board Eligible Child & Adolescent Psychiatrist
Psychiatrist
Psychologist/PNP w/ med. Authority
Other licensed provider
$163 00
$131.44
$111.03
$89 00
INSIGHT INTERACTIVE
90805 90811
90805 90811
90804 90810
90804 90810
Individual psychotherapy (20.30 minutes)
Board Certified/Board Eligible Child & Adolescent Psychiatrist_
Psychiatrist
Psychologist/PNP w/ med. Authority
Other licensed provider
$6E>.72
$6572
$49.53
$37.84
INSIGHT
90807
90807
90806
90806
INTERACTIVE
90813
90813
90812
90812 �
Individual psychotherapy (45-50 minutes)
Board Certified/Board Eligible Child & Adolescent Psychiatrist
Psychiatrist
Psychologist/PNP w/ med. Authority
Other licensed provider
$.(28.58
$(48.58
$98.58
$'5.68
INSIGHT
90809
90809
90808
90808
INTERACTIVE
90815
90815
90814
90814
Individual psychotherapy (75-80 minutes)
Board Certified/Board Eligible Child & Adolescent Psychiatrist
Psychiatrist
Psychologist/PNP w/ med. Authority
Other licensed provider
$164.30
$164.30
$148.59
$113.53
INSIGHT
90853
90853
90853
INTERACTIVE
__. 90857
90857
90857
Group psychotherapy
Psychiatrist
Psychologist/PNP w/ med. Authority
Other licensed provider
$44.52
$44.52
$29.22
Family psychotherapy
90846 w/o pt. present; 90847 w/ pt. present Psychologist/PNP w/ med. Authority, Other licensed provider
—---�_._ _----___-- -------._____..--
90849 multi -family Psychologist/PNP w/ med. Authority, Other licensed provider
90862 SAME CODE FOR ALL
Pharmacological management
Board Certified/Board Eligible Child & Adolescent Psychiatrist
Psychiatrist
PNP with med. Authority
$133.50
$44.52
$55.72
Deschutes County / JBH Personal Services Cortract Page 15 o 17
T1016 SAME CODE FOR ALL
Case Management (per 15 minutes)
Board Certified/Board Eligible Child & Adolescent Psychiatrist
Psychiatrist
Psychologist/PNP w/ med. Authority
Other licensed provider - QMHP
QMHA
$22.25
$22.25
$22.25
$22.25
$15.4
96101
Psychological testing with written report (Per authorized hour)
$94, °31
G0176
G0177
H2O14
H2O32
Skills Training
Activity Therapy (Group) 45 minutes or more
Skill Building (Individual) 45 minutes or more
Skill Training & Development (Group) per 15 minutes
Activity Therapy (Individual) per 15 minutes
$24 93
$47.22
$2 74
$15.74
T1013 Sign Language ! Oral Interpreter Service (per 15 min)
$7.65
H0031
H0032
T1023
H0004
H0036
T1016
T1016HN
90882
90887
Other Services
Mental Health Assessment - non physician
Mental Health Service Plan - non physician
Screening to Determine Appropriate Level of Care
Behavior Health Counseling /therapy per 15 min.
Community Psychiatric Supportive Services, face to face per 15 minutes
Service Coordination - QMHP per 15 minutes
Service Coordination - QMHA per 15 minutes
Environmental Intervention with employers, agencies, institutions
Interpretation or explanation of results to family or other responsible
persons
$1'9.00
$r, 9.00
$°19.00
$ ?2.25
7.87
$22.25
15.74
i' 89.00
)89.00
T1023
T1023
Certificate Of Need
Board Certified/Board Eligible Child & Adolescent Psychiatrist
Psychiatrist
'6163.00
6131,00
H0037
H2O12
Psychiatric Day Treatment Services
Per Day
Per Hour, up to 4 Hours
$152.25
$38.00
H0018
Per Day
Assessment and Evaluation
$320.43
H0019
Per Day
Psychiatric Residential Treatment Services
$300.48
All services, including psychological testing, must be pre -authorized.
All services must be provided by JBH credentialed and contracted providers named on the authorization.
All claims are to be submitted on a HCFA 1500 form according to the billing procedures described in the JBI-+ Provider
Manual
Deschutes County / JBH Personal Services Contract Page 16 c '17
ATTACHMENT C
BRS Services, Fee Schedule, and Service Requirements
A. Outpatient Services for JBH Members: CONTRACTOR will provide Outpatient
Mental Health Services to JBH members pursuant to a written referral. Covered
services may include:
1. Diagnostic Intake/Evaluation
2. Mental Health Assessment
3. Individual Psychotherapy
4. Group Psychotherapy
5. Family Psychotherapy
6. Case Management
7. Pharmacological Management
8. Other OHP covered Mental Health Services as authorized
B. Authorizations: All outpatient mental health services must be pre -authorized.
CONTRACTOR must be in receipt of written authorization to ensure
reimbursement for services rendered.
C. Fees: CONTRACTOR shall be paid through a case rate of $350.00 per month
per Member effective April 1, 2008.
D. Claims Submissions: CONTRACTOR must submit claims to JBH's Third Party
Administrator no later than thirty (30) days following the date of health care
service delivery.
E. Monthly Roster: CONTRACTOR shall submit directly to JBH by the 10th day )f
each calendar month a list of JBH Members placed in the BRS facility during the
previous calendar month. The monthly census shall include the JBH Member s
name, OHP number, admission date, and discharge date (if available).
F. Record Keeping Requirements: CONTRACTOR shall comply with record
keeping requirements:
1. A clinical record shall be maintained for each Member served under this
contract.
2. Client Process Monitoring Form (CPMS) shall be initiated for all new
Members and for Members terminated from service. A copy of the CPMS will
be sent to Division of Addictions and Mental Health at the Department of
Human Services and a copy shall be kept in the medical record.
Deschutes County / JBH Personal Services Cortract
Page 17c'17
Certificate of Self -Insurance
This is to certify that Deschutes County, Oregon is a self-insured entity pursuant
to ORS 30282 and has established a self-insured fund against liability and
property damage arising out of any tort claims against its programs, officers,
agents, employees and volunteers acting within the scope of their employment.
This coverage is applicable under any Deschutes County agreement.
Please refer inquiries to:
Deschutes County Risk Management
Erik Kropp, Risk Manager (541) 388-6584
Judy Sumners, Claims Coordinator (541) 385-1749
Ken Harms, Loss Prevention Specialist (541) 617-4747
1300 NW Wall St., Ste. 200, Bend, OR 97701
Effective Date 9/9/08, no expiration