SHJ25-009 KCJ AND CHPW - PARTIALLY EXECUTED

Home Browse Search

Medicare Advantage Organization ("MA organization"): a public or private entity organized and licensed by a State as a risk -bearing entity (with the exception of provider -sponsored organizations receiving waivers) that is certified by CMS as meeting the MA contract requirements. CHPW is the MA organization for purposes of this Agreement. Member or Enrollee: for purposes of this Agreement, is a Medicare Advantage eligible individual who has enrolled in or elected coverage through CHPW. Provider: (1) any individual who is engaged in the delivery of health care services in a State and is licensed or certified by the State to engage in that activity in the State; and (2) any entity that is engaged in the delivery of health care services in a State and is licensed or certified to deliver those services if such licensing or certification is required by State law or regulation. Related entity: any entity that is related to the MA organization by common ownership or control and (1) performs some of the MA organization's management functions under contract or delegation; (2) furnishes services to Medicare enrollees under an oral or written agreement; or (3) leases real property or sells materials to the MA organization at a cost of more than $2,500 during a contract period. Facility Agreement Requirements. The parties agree to the following terms and conditions: 1. HHS, the Comptroller General, or their designees have the right to audit, evaluate, and inspect any pertinent information for any particular contract period, including, but not limited to, any books, contracts, computer or other electronic systems (including medical records and documentation of the first tier, downstream, and entities related to CMS' contract with CHPW, through ten (10) years from the final date of the final contract period of the contract entered into between CMS and CHPW or from the date of completion of any audit, whichever is later. [42 C.F.R. §§ 422.504(i)(2)(i) and (ii)] 2. Facility will comply with the confidentiality and enrollee record accuracy requirements, including: (1) abiding by all Federal and State laws regarding confidentiality and disclosure of medical records, or other health and enrollment information, (2) ensuring that medical information is released only in accordance with applicable Federal or State law, or pursuant to court orders or subpoenas, (3) maintaining the records and information in an accurate and timely manner, and (4) ensuring timely access by enrollees to the records and information that pertain to them. [42 C.F.R. §§ 422.504(a)(13) and 422.118] 3. Enrollees will not be held liable for payment of any fees that are the legal obligation of CHPW. [42 C.F.R. §§ 422.504(i)(3)(i) and 422.504(g)(1)(i)] 4. For all enrollees eligible for both Medicare and Medicaid, enrollees will not be held liable for Medicare Part A and B cost sharing when the State is responsible for paying such amounts. Providers will be informed of Medicare and Medicaid benefits and rules for enrollees eligible for Medicare and Medicaid. Facility may not impose cost -sharing that exceeds the amount of cost -sharing that would be permitted with respect to the individual under title XIX if the individual were not enrolled in such a plan. Providers will: (1) accept the MA plan payment as payment in full, or (2) bill the appropriate State source. [42 C.F.R. §§ 422.504(i)(3)(i) and 422.504(g)(1)(i)] 2020 Facility Exh 13213 - MAProv Page 44 of 51 Contract #{Contract #}-{PRC Agreement ID}