Common use of Option Two Clause in Contracts

Option Two. a. Contractor shall provide information to County so that County may xxxx applicable other third-parties for services provided by Contractor through this Agreement. County shall retain these revenues and shall not offset these revenues against payments to Contractor. b. Contractor shall provide a copy of the completed Payor Financial Form (Attachment D) and subsequent annual updates for all clients who receive services through this agreement. For clients who begin to receive services during the term of this Agreement, completed Payor Financial Forms shall be provided to the County with client registration forms. For clients who were receiving services prior to the start date of this Agreement and who continue to receive services through this Agreement, completed Payor Financial Forms are due within ten (10) days of the end of the first month of the Agreement. San Mateo County Health System is required to xxxx all other insurance (including Medicare) before billing Medi-Cal for beneficiaries who have other coverage in addition to Medi-Cal. This is called “serial billing.” All claims sent to Medi-Cal without evidence of other insurance having been billed first will be denied. In order to comply with the serial billing requirement you must elect which of the two following options to use in our contract with you. In either case, you will need to establish the eligibility of your clients through the completion of the standard form (Payor Financial Form) used to collect this information. Please select and complete one of the two options below: Our agency will xxxx other insurance, and provide San Mateo County Behavioral Health and Recovery Services (BHRS) with a copy of the Explanation of Benefits provided by that insurance plan before billing BHRS for the remainder. We Caminar elect option one. Signature of authorized agent Name of authorized agent Telephone number Our agency will provide information to San Mateo County Behavioral Health and Recovery Services (BHRS) so that BHRS may xxxx other insurance before billing Medi-Cal on our agency’s behalf. This will include completing the attached client Payor Financial Form and providing it to the BHRS Billing Office with the completed “assignment” that indicates the client’s permission for BHRS to xxxx their insurance. We Caminar elect option two. Signature of authorized agent Name of authorized agent Telephone number Please note if your agency already bills private insurance including Medicare for services you provide, then you must elect Option One. This is to prevent double billing. Please return this completed form to: Xxxxxx Xxxxx, Business Systems Manager Behavioral Health and Recovery Services 000 00xx Xxxxxx Xxx Xxxxx, XX 00000 (650) 573-2284 Client Date of Birth Undocumented? □ Yes □ No If no, Social Security Number (Required) 26.5 (AB3632) □ Yes □ No IEP (SELPA) start date Does Client have Medi-Cal? □ Yes □ No Share of Cost? □ Yes □ No Client’s Medi-Cal Number (BIC Number)? Please attach copy of MEDS Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? □ Yes □ No Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service. FINANCIAL ASSESSMENT – Annual UMDAP (Uniform Method of Determining Ability to Pay) Gross Monthly Income (include all in the Household) A. Self $ B. Parents/Spouse/Domestic Partner ….$ C. Other $ Number of Persons Dependent on Income Allowable Expenses A. Court Ordered Monthly Obligation $ B. Monthly Child Care Payments (Only if Necessary for Employment) $ C. Monthly Dependent Support Payments $ D. Monthly Medical Expense Payments $ E. Monthly Mandated Deductions for Retirement Plan (Do not include Social Security)… $ F. Housing Cost (Mortgage/Rent) $ Asset Amount (List all liquid assets) A. Savings… $ B. Checking… $ C. Stocks… $ Health Plan or Insurance Company (Not employer) Name of Company Street Address City State Zip Insurance Co. phone number Policy Number Group Number Name of Insured Person Relationship to Client Social Security Number of Insured Person (if other than client) Does this Client have Healthy Families Insurance? □ Yes If Yes, complete San Mateo County Mental Health SED form. □ No Does this Client have Healthy Kids Insurance? Does this Client have HealthWorx Insurance.? □ Yes □ Yes □ No □ No I affirm that the statements made herein are true and correct. I understand that I am responsible for paying the UMDAP liability amount or cost of treatment received by myself or by members of my household during each 1-year period. If the cost of service is more than the UMDAP liability amount, I pay the lesser amount. It is my responsibility and I agree to provide verification of income, assets and expenses. If I do not, I will be billed in full for services received. I authorize San Mateo County Mental Health to xxxx all applicable mental health services to Medi-Care and/or my insurance plan, including any services provided under 26.5. I authorize payment of healthcare benefits to San Mateo County Mental Health. Signature of Client or Authorized Person Date Reason if client is unable to sign Client Refused to Sign Authorization: □ (Please check if applicable) Date Reason Name of Interviewer Phone Number Best Time to Contact Below are instructions for accessing the State’s MEDS (Medi-Cal Eligibility Determination System) to determine eligibility and clearing share of cost through the internet If you do not have access to the internet, please call Xxxxxxxxxx Xxxxx (phone: 000-000-0000) or Xxxxxxx Xxxxxx (phone:000-000-0000) to verify eligibility.

Option Two. a. Contractor shall provide information to County so that County may xxxx applicable other third-parties before billing Medi-Cal for services provided by Contractor through this Agreement. The County may withhold payment to Contractor for any and all services pending notification or receipt of such third-party payments or denials of such payments. County may deduct from its payments to Contractor the amount of any such third- party payment. To the extent that County inadvertently makes payments to Contractor for such services rendered, County shall retain these revenues and shall not offset these revenues against payments be entitled to Contractor.recoup such reimbursement b. Contractor shall provide a copy of the completed Payor Financial Form (Attachment D) and subsequent annual updates for all clients who receive services through this agreement. For clients who begin to receive services during the term of this Agreement, completed Payor Financial Forms shall be provided to the County with client registration forms. For clients who were receiving services prior to the start date of this Agreement and who continue to receive services through this Agreement, completed Payor Financial Forms are due within ten (10) days with the first invoice of the end of the first month of the Agreement. San Mateo County Health System is required to xxxx all other insurance (including Medicare) before billing Medi-Cal for beneficiaries who have other coverage in addition to Medi-Cal. This is called “serial billing.” All claims sent to Medi-Cal without evidence of other insurance having been billed first will be denied. In order to comply with the serial billing requirement you must elect which of the two following options to use in our contract with you. In either case, you will need to establish the eligibility of your clients through the completion of the standard form (Payor Financial Form) used to collect this information. Please select and complete one of the two options below: Our agency will xxxx other insurance, and provide San Mateo County Behavioral Health and Recovery Services (BHRS) with a copy of the Explanation of Benefits provided by that insurance plan before billing BHRS for the remainder. We Caminar elect option one. Signature of authorized agent Name of authorized agent Telephone number Our agency will provide information to San Mateo County Behavioral Health and Recovery Services (BHRS) so that BHRS may xxxx other insurance before billing Medi-Cal on our agency’s behalf. This will include completing the attached client Payor Financial Form and providing it to the BHRS Billing Office with the completed “assignment” that indicates the client’s permission for BHRS to xxxx their insurance. We Caminar elect option two. Signature of authorized agent Name of authorized agent Telephone number Please note if your agency already bills private insurance including Medicare Agreement for services you provide, then you must elect Option Oneprovided to said clients. This is to prevent double billing. Please return this completed form to: Xxxxxx Xxxxx, Business Systems Manager Behavioral Health and Recovery Services 000 00xx Xxxxxx Xxx Xxxxx, XX 00000 (650) 573MEDI-2284 Client Date of Birth Undocumented? □ Yes □ No If no, Social Security Number (Required) 26.5 (AB3632) □ Yes □ No IEP (SELPA) start date Does Client have Medi-Cal? □ Yes □ No Share of Cost? □ Yes □ No Client’s Medi-Cal Number (BIC Number)? Please attach copy of MEDS Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MISCAL AND HEALTHY FAMILIES/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? □ Yes □ No Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service. FINANCIAL ASSESSMENT – Annual UMDAP (Uniform Method of Determining Ability to Pay) Gross Monthly Income (include all in the Household) A. Self $ B. ParentsHEALTHY KIDS/Spouse/Domestic Partner ….$ C. Other $ Number of Persons Dependent on Income Allowable Expenses A. Court Ordered Monthly Obligation $ B. Monthly Child Care Payments (Only if Necessary for Employment) $ C. Monthly Dependent Support Payments $ D. Monthly Medical Expense Payments $ E. Monthly Mandated Deductions for Retirement Plan (Do not include Social Security)… $ F. Housing Cost (Mortgage/Rent) $ Asset Amount (List all liquid assets) A. Savings… $ B. Checking… $ C. Stocks… $ Health Plan or Insurance Company (Not employer) Name of Company Street Address City State Zip Insurance Co. phone number Policy Number Group Number Name of Insured Person Relationship to Client Social Security Number of Insured Person (if other than client) Does this Client have Healthy Families Insurance? □ Yes If Yes, complete San Mateo County Mental Health SED form. □ No Does this Client have Healthy Kids Insurance? Does this Client have HealthWorx Insurance.? □ Yes □ Yes □ No □ No I affirm that the statements made herein are true and correct. I understand that I am responsible for paying the UMDAP liability amount or cost of treatment received by myself or by members of my household during each 1-year period. If the cost of service is more than the UMDAP liability amount, I pay the lesser amount. It is my responsibility and I agree to provide verification of income, assets and expenses. If I do not, I will be billed in full for services received. I authorize San Mateo County Mental Health to xxxx all applicable mental health services to Medi-Care and/or my insurance plan, including any services provided under 26.5. I authorize payment of healthcare benefits to San Mateo County Mental Health. Signature of Client or Authorized Person Date Reason if client is unable to sign Client Refused to Sign Authorization: □ (Please check if applicable) Date Reason Name of Interviewer Phone Number Best Time to Contact HEALTH WORKS ELIGIBLITY Below are instructions for accessing the State’s MEDS (Medi-Cal Eligibility Determination System) to determine eligibility and clearing share of cost through the internet If you do not have access to the internet, please call Xxxxxxxxxx Xxxxx (phone: 000-000-0000) or Xxxxxxx Xxxxxx (phone:000-000-0000) to verify eligibility. Instructions for Obtaining Medi-Cal Eligibility Using Internet ➢ Double click on Internet Explorer ➢ Type in the address box: xxxxx://xxx.xxxx-xxx.xx.xxx/eligibility ➢ From the Login Center Transaction Services screen, enter Userid: usually 5 zeros followed by your provider number ➢ Enter state assigned password – call Medi-Cal Provider Relations Phone Support @ 0-000-000-0000 ➢ Click on Submit or press enter ➢ From the Transaction Services screen, double click on Determine Patient’s Eligibility ➢ From Perform Eligibility screen fill in the following fields: ▪ Recipient ID – enter the client’s Social Security # (without dashes) ▪ Date of Birth – enter the client’s DOB (mm/dd/yyyy) ▪ Date of Card Issue – if unknown, enter today’s date (mm/dd/yyyy) ▪ Date of Service – enter the date on which the service is to be performed (mm/dd/yyyy) ▪ Click on Submit or press enter Click on Back - to return to Transaction Services screen Clear – press this button to clear the fields in the form Patient Recall – once any transaction has been performed on a client, pressing this button will fill in the common fields with all of the information from the last transaction. This is useful for using the same client on different transaction (such as an eligibility verification, then a Share of Cost) or for correcting data when a transaction has gone through with incorrect data.

Option Two. a. Contractor shall provide information to County so that County may xxxx applicable other third-parties before billing Medi-Cal for services provided by Contractor through this Agreement. The County may withhold payment to Contractor for any and all services pending notification or receipt of such third-party payments or denials of such payments. County may deduct from its payments to Contractor the amount of any such third- party payment. To the extent that County inadvertently makes payments to Contractor for such services rendered, County shall retain these revenues and shall not offset these revenues against payments be entitled to Contractorrecoup such reimbursement. b. Contractor shall provide a copy of the completed Payor Financial Form (Attachment D) and subsequent annual updates for all clients who receive services through this agreement. For clients who begin to receive services during the term of this Agreement, completed Payor Financial Forms shall be provided to the County with client registration forms. For clients who were receiving services prior to the start date of this Agreement and who continue to receive services through this Agreement, completed Payor Financial Forms are due within ten (10) days with the first invoice of the end of the first month of the AgreementAgreement for services provided to said clients. San Mateo County Mental Health System Services is required to xxxx all other insurance (including Medicare) before billing Medi-Cal for beneficiaries who have other coverage in addition to Medi-Cal. This is called “serial billing.” All claims sent to Medi-Cal without evidence of other insurance having been billed first will be denied. In order to comply with the serial billing requirement you must elect which of the two following options to use in our contract with you. In either case, you will need to establish the eligibility of your clients through the completion of the standard form (Payor Financial Form) used to collect this information. Please select and complete one of the two options below: Our agency will xxxx other insurance, and provide San Mateo County Behavioral Mental Health and Recovery Services (BHRSSMCMHS) with a copy of the Explanation of Benefits provided by that insurance plan before billing BHRS SMCMHS for the remainder. We Caminar (agency name) elect option one. Signature of authorized agent Name of authorized agent Telephone number Our agency will provide information to San Mateo County Behavioral Mental Health and Recovery Services (BHRSSMCMHS) so that BHRS SMCMHS may xxxx other insurance before billing Medi-Cal on our agency’s behalf. This will include completing the attached client Payor Financial Form and providing it to the BHRS SMCMHS Billing Office with the completed “assignment” that indicates the client’s permission for BHRS SMCMHS to xxxx their insurance. We Caminar (agency name) elect option two. Signature of authorized agent Name of authorized agent Telephone number Please note if your agency already bills private insurance including Medicare for services you provide, then you must elect Option One. This is to prevent double billing. Please return this completed form to: Xxxxxx Xxxxx, Business Systems Manager Behavioral Mental Health and Recovery Services 000 00xx Xxxxxx Xxx Xxxxx, XX 00000 (650) 573-2284 Client Date Contractor hereby certifies that Contractor’s employees, volunteers, consultants, agents, and any other persons who provide services under this Agreement and who has/will have supervisory or disciplinary power over a child (Penal Code Section 11105.3) (the “Applicant”) shall be fingerprinted in order to determine whether each such Applicant has a criminal history which would compromise the safety of Birth Undocumented? □ Yes □ No If no, Social Security Number (Required) 26.5 (AB3632) □ Yes □ No IEP (SELPA) start date Does Client children with whom each such Applicant has/will have Medi-Cal? □ Yes □ No Share of Cost? □ Yes □ No Client’s Medi-Cal Number (BIC Number)? Please attach copy of MEDS Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? □ Yes □ No Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service. FINANCIAL ASSESSMENT – Annual UMDAP (Uniform Method of Determining Ability to Pay) Gross Monthly Income (include all in the Household) A. Self $ B. Parents/Spouse/Domestic Partner ….$ C. Other $ Number of Persons Dependent on Income Allowable Expenses A. Court Ordered Monthly Obligation $ B. Monthly Child Care Payments (Only if Necessary for Employment) $ C. Monthly Dependent Support Payments $ D. Monthly Medical Expense Payments $ E. Monthly Mandated Deductions for Retirement Plan (Do not include Social Security)… $ F. Housing Cost (Mortgage/Rent) $ Asset Amount (List all liquid assets) A. Savings… $ B. Checking… $ C. Stocks… $ Health Plan or Insurance Company (Not employer) Name of Company Street Address City State Zip Insurance Co. phone number Policy Number Group Number Name of Insured Person Relationship to Client Social Security Number of Insured Person (if other than client) Does this Client have Healthy Families Insurance? □ Yes If Yes, complete San Mateo County Mental Health SED form. □ No Does this Client have Healthy Kids Insurance? Does this Client have HealthWorx Insurance.? □ Yes □ Yes □ No □ No I affirm that the statements made herein are true and correct. I understand that I am responsible for paying the UMDAP liability amount or cost of treatment received by myself or by members of my household during each 1-year periodcontact. If the cost of service is more than the UMDAP liability amountsaid employees and/or subcontractors, I pay the lesser amount. It is my responsibility assignees, and I agree to provide verification of incomevolunteers have such a criminal history, assets and expenses. If I do not, I will be billed in full for services received. I authorize San Mateo County Mental Health to xxxx all applicable mental health services to Medi-Care and/or my insurance plan, including any services provided under 26.5. I authorize payment of healthcare benefits to San Mateo County Mental Health. Signature of Client or Authorized Person Date Reason if client is unable to sign Client Refused to Sign Authorization: □ (Please check if applicable) Date Reason Name of Interviewer Phone Number Best Time to Contact Below are instructions for accessing the State’s MEDS (Medi-Cal Eligibility Determination System) to determine eligibility and clearing share of cost through the internet If you do they shall not have access to the internetcontact with children who receive services through this Agreement. Contractor’s employees, please call Xxxxxxxxxx Xxxxx volunteers, consultants, agents, and any other persons who provide services under this Agreement: (phone: 000-000-0000) check a or Xxxxxxx Xxxxxx (phone:000-000-0000) to verify eligibility.b)

Option Two. a. Contractor shall provide information to County so that County may xxxx applicable other third-parties before billing Medi-Cal for services provided by Contractor through this Agreement. The amount of any such third- party payment shall be deducted from the total actual costs for all services rendered by Contractor as reflected on the Cost Report as defined in Paragraph K. of this Exhibit B. County accepts no financial responsibility for services provided to beneficiaries where there is a responsible third party payor, and to the extent that County inadvertently makes payments to Contractor for such services rendered, County shall retain these revenues and shall not offset these revenues against payments be entitled to Contractorrecoup such reimbursement through the Cost Report reconciliation. b. Contractor shall provide a copy of the completed Payor Financial Form (Attachment D) and subsequent annual updates for all clients who receive services through this agreement. For clients who begin to receive services during the term of this I. County anticipates revenues from various sources to be used to fund services provided by Contractor through this Agreement. Should actual revenues be less than the amounts anticipated for any period of this Agreement, completed Payor Financial Forms the maximum payment obligation and/or payment obligations for specific services may be reduced at the discretion of the Chief of the Health System or the Chief’s designee. J. In the event of a decrease in the Xxxxx-Xxxxx/Medi-Cal Maximum Reimbursement Rates for services provided pursuant to this Agreement, Contractor agrees to either accept rate(s) not to exceed the Xxxxx-Xxxxx/Medi-Cal Maximum Reimbursement Rates or to discontinue provision of these services as of the effective date for the new rate(s) is/are less than the rate(s) established in this Agreement, it is agreed the rate(s) will be changed to the Xxxxx-Xxxxx/Medi-Cal Maximum Reimbursement Rates. In no event shall the compensation rate(s) for services provided under this Agreement exceed the Xxxxx- Xxxxx/Medi-Cal Reimbursement Rates. K. If County or Contractor finds that performance is inadequate, at the County’s discretion, a meeting may be called to discuss the causes for the performance problem, and this Agreement may either be renegotiated, allowed to continue to end of term, or terminated pursuant to Paragraph 4 of this Agreement. Any unspent monies due to performance failure may reduce the following year's agreement, if any. L. In the event Contractor claims or receives payment from County for a service, reimbursement for which is later disallowed by County or the State of California or the United States Government, then Contractor shall promptly refund the disallowed amount to County upon request, or, at its option, County may offset the amount disallowed from any payment due or become due to Contractor under this Agreement or any other agreement. M. Contractor shall provide all pertinent documentation required for federal Medi-Cal reimbursement (including initial and quarterly notices, assessment and service plans, and progress notes). The County may withhold payment for any and all services for which the required documentation is not provided, or if the documentation provided does not meet professional standards as determined by the Quality Improvement Manager of the San Mateo County BHRS Division of the County Health System. N. In the event this Agreement is terminated prior to June 30, 2011, Contractor shall be paid on a prorated basis for only that portion of the contract term during which Contractor provided services pursuant to this Agreement. Such billing shall be subject to the approval of the Chief of the Health System or the Chief’s designee. O. Cost Report 1. Contractor shall submit to County a year-end cost report no later than ninety (90) days after the expiration date of this Agreement. This report shall be in accordance with the principles and format outlined in the Cost Reporting/Data Collection (CR/DC) Manual. Contractor shall annually have its books of accounts audited by a Certified Public Accountant and a copy of said audit report shall be submitted along with the Cost Report. 2. If the annual Cost Report provided to County shows that total payment to Contractor exceed the total actual costs for all of the services rendered by Contractor to eligible patients during the reporting period, a single payment in the amount of the contract savings shall be made to County by Contractor, unless otherwise authorized by the Chief of the Health System or the Chief’s designee. By mutual agreement of County and Contractor, contract savings or “rollover” may be retained by Contractor and expended the following year, provided that these funds are expended for mental health services approved by County and are retained in accordance with Paragraph I.O of this Exhibit B. 3. Where discrepancies between costs and charges are found on the Cost Report to County, Contractor shall make a single payment to County when the total charges exceed the total actual costs for all of the services rendered to eligible patients during the reporting period. Likewise, a single payment shall be made to Contractor by County when the total actual costs exceed the total charges made for all of the services rendered to eligible patients during the reporting period and shall not exceed the total amount in Paragraph I.A.1 of this Exhibit B. P. Beneficiary Billing Contractor shall not submit a claim to, demand or otherwise collect reimbursement from, the beneficiary or persons acting on behalf of the beneficiary for any specialty mental health or related administrative services provided under this contract except to collect other health insurance coverage, share of cost and co-payments. The Contractor shall not hold beneficiaries liable for debts in the event that the County becomes insolvent, for costs of covered services for which the State does not pay the County, for costs of covered services for which the State or the County does not pay the Contractor, for costs of covered services provided under this or other contracts, referral or other arrangement rather than from the County, or for payment of subsequent screening and treatment needed to diagnose the specific condition of or stabilize a beneficiary with an emergency psychiatric condition. Q. Claims Certification and Program Integrity 1. Contractor shall comply with all state and federal statutory and regulatory requirements for certification of claims, including Title 42, Code of Federal Regulations (CFR) Part 438, Sections 438.604, 438.606, and, as effective August 13, 2003, Section 438.608, as published in the June 14, 2002 Federal Register (Vol. 67, No. 115, Page 41112), which are hereby incorporated by reference. 2. Anytime Contractor submits a claim to the County for reimbursement for services provided under Exhibit A of this Agreement, Contractor shall certify by signature that the claim is true and accurate by stating the claim is submitted under the penalty of perjury under the laws of the State of California. The claim must include the following language and signature line at the bottom of the form(s) and/or cover letter used to report the claim. Executed at California, on , 20 Signed Title Agency ” 3. The certification shall attest to the following for each beneficiary with services included in the claim: a. An assessment of the beneficiary was conducted in compliance with the requirements established in this agreement. b. The beneficiary was eligible to receive services described in Exhibit A of this Agreement at the time the services were provided to the County beneficiary. c. The services included in the claim were actually provided to the beneficiary. d. Medical necessity was established for the beneficiary as defined under California Code of Regulations, Title 9, Division 1, Chapter 11, for the service or services provided, for the timeframe in which the services were provided. e. A client plan was developed and maintained for the beneficiary that met all client plan requirements established in this agreement. f. For each beneficiary with client registration forms. For clients who specialty mental health services included in the claim, all requirements for Contractor payment authorization for specialty mental health services were receiving met, and any reviews for such service or services were conducted prior to the start date of initial authorization and any re-authorization periods as established in this Agreement agreement. g. Services are offered and who continue to receive services through this Agreementprovided without discrimination based on race, completed Payor Financial Forms are due within ten (10) days of the end of the first month of the Agreement. San Mateo County Health System is required to xxxx all other insurance (including Medicare) before billing Medi-Cal for beneficiaries who have other coverage in addition to Medi-Cal. This is called “serial billingreligion, color, national or ethnic origin, sex, age, or physical or mental disability.” All claims sent to Medi-Cal without evidence of other insurance having been billed first will be denied. In order to comply with the serial billing requirement you must elect which of the two following options to use in our contract with you. In either case, you will need to establish the eligibility of your clients through the completion of the standard form (Payor Financial Form) used to collect this information. Please select and complete one of the two options below: Our agency will xxxx other insurance, and provide San Mateo County Behavioral Health and Recovery Services (BHRS) with a copy of the Explanation of Benefits provided by that insurance plan before billing BHRS for the remainder. We Caminar elect option one. Signature of authorized agent Name of authorized agent Telephone number Our agency will provide information to San Mateo County Behavioral Health and Recovery Services (BHRS) so that BHRS may xxxx other insurance before billing Medi-Cal on our agency’s behalf. This will include completing the attached client Payor Financial Form and providing it to the BHRS Billing Office with the completed “assignment” that indicates the client’s permission for BHRS to xxxx their insurance. We Caminar elect option two. Signature of authorized agent Name of authorized agent Telephone number Please note if your agency already bills private insurance including Medicare for services you provide, then you must elect Option One. This is to prevent double billing. Please return this completed form to: Xxxxxx Xxxxx, Business Systems Manager Behavioral Health and Recovery Services 000 00xx Xxxxxx Xxx Xxxxx, XX 00000 (650) 573-2284 Client Date of Birth Undocumented? □ Yes □ No If no, Social Security Number (Required) 26.5 (AB3632) □ Yes □ No IEP (SELPA) start date Does Client have Medi-Cal? □ Yes □ No Share of Cost? □ Yes □ No Client’s Medi-Cal Number (BIC Number)? Please attach copy of MEDS Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? □ Yes □ No Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service. FINANCIAL ASSESSMENT – Annual UMDAP (Uniform Method of Determining Ability to Pay) Gross Monthly Income (include all in the Household) A. Self $ B. Parents/Spouse/Domestic Partner ….$ C. Other $ Number of Persons Dependent on Income Allowable Expenses A. Court Ordered Monthly Obligation $ B. Monthly Child Care Payments (Only if Necessary for Employment) $ C. Monthly Dependent Support Payments $ D. Monthly Medical Expense Payments $ E. Monthly Mandated Deductions for Retirement Plan (Do not include Social Security)… $ F. Housing Cost (Mortgage/Rent) $ Asset Amount (List all liquid assets) A. Savings… $ B. Checking… $ C. Stocks… $ Health Plan or Insurance Company (Not employer) Name of Company Street Address City State Zip Insurance Co. phone number Policy Number Group Number Name of Insured Person Relationship to Client Social Security Number of Insured Person (if other than client) Does this Client have Healthy Families Insurance? □ Yes If Yes, complete San Mateo County Mental Health SED form. □ No Does this Client have Healthy Kids Insurance? Does this Client have HealthWorx Insurance.? □ Yes □ Yes □ No □ No I affirm that the statements made herein are true and correct. I understand that I am responsible for paying the UMDAP liability amount or cost of treatment received by myself or by members of my household during each 1-year period. If the cost of service is more than the UMDAP liability amount, I pay the lesser amount. It is my responsibility and I agree to provide verification of income, assets and expenses. If I do not, I will be billed in full for services received. I authorize San Mateo County Mental Health to xxxx all applicable mental health services to Medi-Care and/or my insurance plan, including any services provided under 26.5. I authorize payment of healthcare benefits to San Mateo County Mental Health. Signature of Client or Authorized Person Date Reason if client is unable to sign Client Refused to Sign Authorization: □ (Please check if applicable) Date Reason Name of Interviewer Phone Number Best Time to Contact Below are instructions for accessing the State’s MEDS (Medi-Cal Eligibility Determination System) to determine eligibility and clearing share of cost through the internet If you do not have access to the internet, please call Xxxxxxxxxx Xxxxx (phone: 000-000-0000) or Xxxxxxx Xxxxxx (phone:000-000-0000) to verify eligibility.