Common use of Payment for Services Clause in Contracts

Payment for Services. i. For claiming Federal Financial Participation (FFP), the Contractor shall certify the total allowable expenditures incurred in providing the DMC-ODS services provided either through Contractor operated providers, contracted fee-for-service providers or contracted managed care plans. ii. DHCS shall establish a Center for Medicare and Medicaid Services (CMS) approved Certified Public Expenditure (CPE) protocol before FFP associated with DMC-ODS services, is made available to DHCS. This DHCS approved CPE protocol (Attachment AA of the STCs) shall explain the process DHCS shall use to determine costs incurred by the counties under this demonstration. iii. The Contractor shall only provide State Plan DMC services until DHCS and CMS approve of this Agreement and the approved Agreement is executed by the Contractor’s County Board of Supervisors. During this time, State Plan DMC services shall be reimbursed pursuant to the State Plan reimbursement methodologies. iv. Pursuant to Title 42 CFR 433.138 and 22 CCR 51005(a), if a beneficiary has Other Heath Coverage (OHC), then the Contractor shall xxxx that OHC prior to billing DMC to receive either payment from the OHC, or a notice of denial from the OHC indicating that: a. The recipient’s OHC coverage has been exhausted, or b. The specific service is not a benefit of the OHC. v. If the Contractor submits a claim to an OHC and receives partial payment of the claim, the Contractor may submit the claim to DMC and is eligible to receive payment up to the maximum DMC rate for the service, less the amount of the payment made by the OHC.

Payment for Services. i. For The Contractor shall pay the subcontractor the per utilizer per month (PUPM) rate identified in Exhibit B, Part V, ii. The Contractor or its subcontractor shall submit a claim to the Department’s Xxxxx-Xxxxx Medi-Cal claiming Federal Financial Participation (FFP), system for each DMC ODS service the subcontractor provides to a Medi-Cal beneficiary. iii. The Contractor shall certify the total allowable public expenditures incurred in providing the to provide all DMC-ODS services provided either through Contractor operated providers, contracted feefor Medi-for-service providers or contracted managed care plansCal beneficiaries. iiiv. DHCS shall reimburse the Contractor in accordance with the sharing ratios identified in Exhibit B, Part V, Provision C to this Agreement. v. The Contractor shall attest to the accuracy, completeness, and truthfulness of claims and payment data, under penalty of perjury. vi. DHCS shall establish a Center for Medicare and Medicaid Services (CMS) -approved Certified Public Expenditure (CPE) protocol before reimbursing the Contractor for any FFP associated with DMC-ODS services, is made available to DHCS. This DHCS CMS-approved CPE protocol (Attachment AA of the STCs) shall explain define the process by which DHCS shall use to determine costs incurred by will reimburse the counties under this demonstrationContractor. iiivii. The Contractor shall only provide State Plan DMC services until DHCS and CMS approve of this Agreement and the approved Agreement is executed by the Contractor’s County Board of Supervisors. During this time, State Plan DMC services shall be reimbursed pursuant to the State Plan reimbursement methodologies. ivviii. Pursuant to Title 42 CFR 433.138 and 22 CCR 51005(a), if a beneficiary has Other Heath Coverage (OHC), then the Contractor shall xxxx that OHC prior to billing DMC to receive either payment from the OHC, or a notice of denial from the OHC indicating that: a. The recipient’s OHC coverage has been exhausted, or b. The specific service is not a benefit of the OHC. v. ix. If the Contractor or subcontractor submits a claim to an for OHC and receives partial payment of the claim, the Contractor may submit the claim to DMC and is eligible to receive payment up to the maximum DMC rate for the service, less the amount of the payment made by the OHC.Department’s Xxxxx-Xxxxx Medi-

Payment for Services. i. For claiming Federal Financial Participation (FFP), the Contractor shall certify the total allowable expenditures incurred in providing the DMC-ODS services provided either through Contractor operated providers, contracted fee-for-for- service providers or contracted managed care plans. ii. DHCS shall establish a Center for Medicare and Medicaid Services (CMS) approved Certified Public Expenditure (CPE) protocol before FFP associated with DMC-ODS services, is made available to DHCS. This DHCS approved CPE protocol (Attachment AA of the STCs) shall explain the process DHCS shall use to determine costs incurred by the counties under this demonstration. iii. The Contractor shall only provide State Plan DMC services until DHCS and CMS approve of this Agreement and the approved Agreement is executed by the Contractor’s County Board of Supervisors. During this time, State Plan DMC services shall be reimbursed pursuant to the State Plan reimbursement methodologies. iv. Pursuant to Title 42 CFR 433.138 and 22 CCR 51005(a), if a beneficiary has Other Heath Coverage (OHC), then the Contractor shall xxxx that OHC prior to billing DMC to receive either payment from the OHC, or a notice of denial from the OHC indicating that: a. The recipient’s OHC coverage has been exhausted, or b. The specific service is not a benefit of the OHC. v. If the Contractor submits a claim to an OHC and receives partial payment of the claim, the Contractor may submit the claim to DMC and is eligible to receive payment up to the maximum DMC rate for the service, less the amount of the payment made by the OHC.

Payment for Services. i. For The Contractor shall pay the subcontractor the per utilizer per month (PUPM) rate identified in Exhibit B, Part V, ii. The Contractor or its subcontractor shall submit a claim to the Department’s Xxxxx-Xxxxx Medi-Cal claiming Federal Financial Participation (FFP), system for each DMC ODS service the subcontractor provides to a Medi-Cal beneficiary. iii. The Contractor shall certify the total allowable public expenditures incurred in providing the to provide all DMC-ODS services provided either through Contractor operated providers, contracted feefor Medi-for-service providers or contracted managed care plansCal beneficiaries. iiiv. DHCS shall reimburse the Contractor in accordance with the sharing ratios identified in Exhibit B, Part V, Provision C to this Agreement. v. The Contractor shall attest to the accuracy, completeness, and truthfulness of claims and payment data, under penalty of perjury. vi. DHCS shall establish a Center for Medicare and Medicaid Services (CMS) -approved Certified Public Expenditure (CPE) protocol before reimbursing the Contractor for any FFP associated with DMC-ODS services, is made available to DHCS. This DHCS CMS-approved CPE protocol (Attachment AA of the STCs) shall explain define the process by which DHCS shall use to determine costs incurred by will reimburse the counties under this demonstrationContractor. iiivii. The Contractor shall only provide State Plan DMC services until DHCS and CMS approve of this Agreement and the approved Agreement is executed by the Contractor’s County Board of Supervisors. During this time, State Plan DMC services shall be reimbursed pursuant to the State Plan reimbursement methodologies. ivviii. Pursuant to Title 42 CFR 433.138 and 22 CCR 51005(a), if a beneficiary has Other Heath Coverage (OHC), then the Contractor shall xxxx bill that OHC prior to billing DMC to receive either payment from the OHC, or a notice of denial from the OHC indicating that: a. The recipient’s OHC coverage has been exhausted, or b. The specific service is not a benefit of the OHC. v. ix. If the Contractor or subcontractor submits a claim to an for OHC and receives partial payment of the claim, the Contractor may submit the claim to DMC and is eligible to receive payment up to the maximum DMC rate for the service, less the amount of the payment made by the OHC.Department’s Xxxxx-Xxxxx Medi-

Payment for Services. Exhibit A, Attachment I i. For claiming Federal Financial Participation (FFP), the Contractor shall certify the total allowable expenditures incurred in providing the DMC-ODS services provided either through Contractor operated providers, contracted fee-for-service providers or contracted managed care plans. ii. DHCS shall establish a Center for Medicare and Medicaid Services (CMS) approved Certified Public Expenditure (CPE) protocol before FFP associated with DMC-ODS services, is made available to DHCS. This DHCS approved CPE protocol (Attachment AA of the STCs) shall explain the process DHCS shall use to determine costs incurred by the counties under this demonstration. iii. The Contractor shall only provide State Plan DMC services until DHCS and CMS approve of this Agreement and the approved Agreement is executed by the Contractor’s County Board of Supervisors. During this time, State Plan DMC services shall be reimbursed pursuant to the State Plan reimbursement methodologies. iv. Pursuant to Title 42 CFR 433.138 and 22 CCR 51005(a), if a beneficiary has Other Heath Coverage (OHC), then the Contractor shall xxxx that OHC prior to billing DMC to receive either payment from the OHC, or a notice of denial from the OHC indicating that: a. The recipient’s OHC coverage has been exhausted, or b. The specific service is not a benefit of the OHC. v. If the Contractor submits a claim to an OHC and receives partial payment of the claim, the Contractor may submit the claim to DMC and is eligible to receive payment up to the maximum DMC rate for the service, less the amount of the payment made by the OHC.

Payment for Services. Exhibit A, Attachment I A1 i. For claiming Federal Financial Participation (FFP), the Contractor shall certify the total allowable expenditures incurred in providing the DMC-ODS services provided either through Contractor operated providers, contracted fee-for-service providers or contracted managed care plans. ii. DHCS shall establish a Center for Medicare and Medicaid Services (CMS) approved Certified Public Expenditure (CPE) protocol before FFP associated with DMC-ODS services, is made available to DHCS. This DHCS approved CPE protocol (Attachment AA of the STCs) shall explain the process DHCS shall use to determine costs incurred by the counties under this demonstration. iii. The Contractor shall only provide State Plan DMC services until DHCS and CMS approve of this Agreement and the approved Agreement is executed by the Contractor’s County Board of Supervisors. During this time, State Plan DMC services shall be reimbursed pursuant to the State Plan reimbursement methodologies. iv. Pursuant to Title 42 CFR 433.138 and 22 CCR 51005(a), if a beneficiary has Other Heath Coverage (OHC), then the Contractor shall xxxx that OHC prior to billing DMC to receive either payment from the OHC, or a notice of denial from the OHC indicating that: a. The recipient’s OHC coverage has been exhausted, or b. The specific service is not a benefit of the OHC. v. If the Contractor submits a claim to an OHC and receives partial payment of the claim, the Contractor may submit the claim to DMC and is eligible to receive payment up to the maximum DMC rate for the service, less the amount of the payment made by the OHC.

Payment for Services. i. For claiming Federal Financial Participation (FFP), the Contractor shall certify the total allowable expenditures incurred in providing the DMC-ODS services provided either through Contractor operated providers, contracted fee-for-for- service providers or contracted managed care plans. ii. DHCS shall establish a Center for Medicare and Medicaid Services (CMS) approved Certified Public Expenditure (CPE) protocol before FFP associated with DMC-ODS services, is made available to DHCS. This DHCS approved CPE protocol (Attachment AA of the STCs) shall explain the process DHCS shall use to determine costs incurred by the counties under this demonstration. iii. The Contractor shall only provide State Plan DMC services until DHCS and CMS approve of this Agreement and the approved Agreement is executed by the Contractor’s County Board of Supervisors. During this time, State Plan DMC services shall be reimbursed pursuant to the State Plan reimbursement methodologies. iv. Pursuant to Title 42 CFR 433.138 and 22 CCR 51005(a), if a beneficiary has Other Heath Coverage (OHC), then the Contractor shall xxxx bill that OHC prior to billing DMC to receive either payment from the OHC, or a notice of denial from the OHC indicating that: a. The recipient’s OHC coverage has been exhausted, or b. The specific service is not a benefit of the OHC. v. If the Contractor submits a claim to an OHC and receives partial payment of the claim, the Contractor may submit the claim to DMC and is eligible to receive payment up to the maximum DMC rate for the service, less the amount of the payment made by the OHC.

Payment for Services. i. For claiming Federal Financial Participation (FFP), the Contractor shall certify the total allowable expenditures incurred in providing the DMC-ODS services provided either through Contractor operated providers, contracted fee-for-service providers or contracted managed care plans. ii. The Contractor shall attest to the accuracy, completeness, and truthfulness of claims and payment data, under penalty of perjury. iii. DHCS shall establish a Center for Medicare and Medicaid Services (CMS) -approved Certified Public Expenditure (CPE) protocol before FFP associated with DMC-ODS services, is services are made available to DHCS. This DHCS approved CPE protocol (Attachment AA of the STCs) shall explain the process DHCS shall use to determine costs incurred by the counties under this demonstrationprogram. iiiiv. The Contractor shall only provide State Plan DMC services until DHCS and CMS approve of this Agreement and the approved Agreement is executed by the Contractor’s County Board of Supervisors. During this time, State Plan DMC services shall be reimbursed pursuant to the State Plan reimbursement methodologies. iv. v. Pursuant to Title 42 CFR 433.138 and 22 CCR Cal. Code Regs., tit. 22, § 51005(a), if a beneficiary has Other Heath Coverage (OHC), then the Contractor shall xxxx bill that OHC prior to billing DMC to receive either payment from the OHC, or a notice of denial from the OHC indicating that: a. The recipient’s OHC coverage has been exhausted, . or b. The specific service is not a benefit of the OHC. v. vi. If the Contractor submits a claim to an OHC and receives partial payment of the claim, the Contractor may submit the claim to DMC and is eligible to receive payment up to the maximum DMC rate for the service, less the amount of the payment made by the OHC.