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DocuSign Envelope ID: 666BF09F-322B-4B60-BCBO-40579A7ED52C <br />4.2 Monthly Data Collection Spreadsheet. <br />4.2.1 Data spreadsheet filled out completely with Section 4.2.3 below, following template <br />provided by HCA and shared via the Managed File Transfer (MFT) portal. <br />4.2.2 Participation requires performance monitoring activities, including timely and accurate <br />data reporting to the Health Care Authority, Division of Behavioral Health and Recovery <br />(HCA DBHR). Further evaluation, including on- and off -site data collection may be <br />conducted by HCA DBHR or a third party. <br />4.2.3 The contractor will submit a monthly report, template provided by HCA DBHR, by the <br />10th day of the month with the following participant information, (identified as having a <br />current OUD), for the previous month: <br />4.2.3.1 Full name. <br />4.2.3.2 Date of birth. <br />4.2.3.3 Provider One #, SSN or another unique identifier. <br />4.2.3.4 Date of booking. <br />4.2.3.5 Date MOUD started: continued or induction? <br />4.2.3.6 Date of release if applicable. <br />4.2.3.7 Schedule first appointment upon release. <br />4.2.3.8 Which MOUD provided upon release. <br />4.2.4 Information will be collected via the Managed File Transfer (MFT). It may be shared with <br />Research Data and Analysis (RDA) for evaluation purposes. <br />5. Allowable expenses. The following is a list of allowable expenses. Contractor shall submit items not on this <br />list to HCA Contract Manager for approval before purchasing. <br />5.1 Program Staff. <br />5.1.1 <br />5.1.2 <br />5.1.3 <br />5.1.4 <br />5.1.5 <br />5.1.6 <br />Nursing. <br />Medical assistants. <br />Providers, prescribers. <br />Correctional staff. <br />Clerical or administrative staff for program reporting and administration. <br />Care navigators, reentry coordinators, peer support, substance use disorder professionals, <br />community health workers. <br />Washington State Page 8 of 10 MOUD in Jails Services <br />Health Care Authority HCA Contract No. K5885-3 <br />Schedule A-3 <br />