Common use of PROVIDER AGREES TO THE FOLLOWING Clause in Contracts

PROVIDER AGREES TO THE FOLLOWING. 1. Provider is currently a non-profit service organization as defined in ARSD Chapter 67:16:25:01. 2. Provider agrees to promptly notify Finance/EBT if there is a change in Provider's name or address or if there is a change of ownership or corporate entity of Provider. Provider further agrees to supply all documentation necessary for the reimbursement of any outstanding claims upon termination from the Title XIX Non-Emergency Medical Transportation program. 3. Provider agrees to comply with all Federal and State laws, regulations and rules applicable to Provider's participation in the Title XIX Non-Emergency Medical Transportation program, including program regulations located in ARSD Chapter 67:16:25. 4. Provider agrees to provide services as required by the recipient and only in the amount required by the recipient without discrimination on the grounds of age, race, color, sex, national origin, physical or mental disability, marital or economic status. 5. Provider agrees to keep complete and accurate fiscal records that fully justify and disclose the extent of the services rendered and xxxxxxxx made under the Title XIX Non-Emergency Medical Transportation program, and agrees to furnish Finance/EBT and/or Medicaid Fraud Control Unit (MFCU) and/or Department of Health & Human Services (HHS), upon request and allow access to pertinent financial records, such information regarding any payments claimed for providing these services. Access includes, but is not limited to, the examination, inspection, photocopying and/or auditing of any requested financial records. Provider understands that failure to submit or failure to retain adequate documentation for all services billed to the Title XIX Non- Emergency Medical Transportation program may result in recovery of payments for medical transportation services not adequately documented, and may result in the termination or suspension of Provider from participation in the Title XIX Non- Emergency Medical Transportation program, and may result in civil or criminal liability. 6. Provider acknowledges that by submitting a claim to the Title XIX Non-Emergency Medical Transportation program, Provider certifies that the transportation expenses were advanced to the program recipient prior to the submission of the claim to the Title XIX Non-Emergency Medical Transportation program. 7. Provider agrees to allow Finance/EBT and/or MFCU and/or HHS access to any and all financial records which may be deemed confidential by any regulatory or licensing agency, board or commission. 8. Provider agrees to submit claims in accordance with billing instructions and as required under any and all state regulations. 9. Provider agrees to submit claims that are true, accurate, and complete. Provider acknowledges by Provider's signature on this agreement that Provider understands that payment and satisfaction of each claim will be from Federal and State funds and that any false claims, statements or documents, or concealment of material fact, may be prosecuted under applicable Federal and State law. 10. Provider agrees to not make or cause to be made a claim, knowing the claim to be false, in whole or in part, by commission or omission or in any other respect contrary to the provisions of SDCL ch.22-45. 11. Provider agrees that claims for services rendered to Title XIX Non-Emergency Medical Transportation program recipients shall not exceed the established program rates located in ARSD Chapter 67:16:25:07.04. 12. Provider agrees to accept as payment in full the amounts paid in accordance with established reimbursement rates. The Provider understands that the pre-determined amount provided by the Title XIX Non-Emergency Medical Transportation program is an estimate based on the information provided and that a reimbursement determination will be made upon completion of the medical trip, receipt of all required forms and documentation and verification of covered services. The pre-determination process is not a guarantee of reimbursement. 13. Provider acknowledges the time limits for submission of Title XIX Non-Emergency Medical Transportation claims as defined in ARSD Chapter 67:16:35:04. 14. Provider acknowledges that Finance/EBT is the payer of last resort (subject to certain exceptions) and acknowledges its obligation to pursue payment from all other liable parties. Provider further agrees that in the event Provider receives payment from the Title XIX Non-Emergency Medical Transportation program in error or in excess of the amount properly due under the applicable rules and procedures, Provider will promptly notify Finance/EBT and arrange for the return of any excess money so received. 15. Provider agrees that failure to comply with any portion of this Provider Agreement will be good cause for termination of this agreement. 16. Provider agrees that any improper submission of claims, or actions deemed an abuse of the Title XIX Non-Emergency Medical Transportation program, or actions involving Title XIX Non-Emergency Medical Transportation program abuse which result in administrative, civil or criminal liability, will be good cause for termination of this agreement. 17. This agreement will be automatically terminated if Provider is convicted (including any form of suspended sentence) of any crime determined to be detrimental to the best interests of the Title XIX Non-Emergency Medical Transportation program.

PROVIDER AGREES TO THE FOLLOWING. 1. Provider is currently a non-profit service organization as defined licensed to practice and in ARSD Chapter 67:16:25:01good standing in the State of South Dakota or in Provider's resident State. 2. Provider agrees to promptly notify Finance/EBT Medical Services if there is a change in Provider's name or address or address, if there is a change of ownership or corporate entity of Provider, or if Provider's license is revoked or suspended. Provider further agrees to supply all documentation necessary for the reimbursement of any outstanding claims upon termination from the Title XIX Non-Emergency Medical Transportation medical assistance program. 3. Provider agrees to comply with all Federal and State laws, regulations and rules applicable to Provider's participation in the Title XIX Nonmedical assistance program. Provider also agrees to abide by regulations and rules adopted during the term of the provider agreement pursuant to SDCL Chapter 1-Emergency Medical Transportation program, including program regulations located in ARSD Chapter 67:16:2526 or 5 USC §553. 4. Provider agrees to provide medically necessary goods and services as required by the recipient and only in the amount required by the recipient without discrimination on the grounds of age, race, color, sex, national origin, physical or mental disability, marital or economic status. 5. Provider agrees to keep complete and accurate medical and fiscal records that fully justify and disclose the extent of the services rendered and xxxxxxxx made under the Title XIX Non-Emergency Medical Transportation medical assistance program, and agrees to furnish Finance/EBT Medical Services and/or Medicaid Fraud Control Unit (MFCU) and/or Department of Health & Human Services (HHS), upon request and allow access to pertinent financial recordsrequest, such information regarding any payments claimed for providing these services. Provider agrees to obtain a written waiver of the physician-patient privilege and release of medical records from each patient for the purposes of allowing access to the pertinent patient records and facilities by Medical Services, MFCU and/or HHS. Access includes, but is not limited to, the examination, inspection, photocopying and/or auditing of any requested financial records. Provider understands that failure to submit or failure to retain adequate documentation for all services billed to the Title XIX Non- Emergency Medical Transportation medical assistance program may result in recovery of payments for medical transportation services not adequately documented, and may result in the termination or suspension of Provider from participation in the Title XIX Non- Emergency Medical Transportation medical assistance program, and may result in civil or criminal liability. 6. Provider acknowledges that by submitting a claim to the Title XIX Non-Emergency Medical Transportation medical assistance program, Provider certifies that the transportation expenses services were advanced to the program recipient medically necessary, were rendered prior to the submission of the claim to the Title XIX Non-Emergency Medical Transportation medical assistance program and that the services were rendered by Provider or incident to Provider's professional service by an employee, and in the case of an individual practitioner, under Provider's immediate personal supervision as permitted by the medical assistance program. 7. Provider agrees to allow Finance/EBT Medical Services and/or MFCU and/or HHS access to any and all financial records materials which may be deemed confidential by any regulatory or licensing agency, board or commission. 8. Provider agrees to submit claims in accordance with billing instructions and as required under any and all state regulations. 9. Provider agrees to submit claims that are true, accurate, and complete. Provider acknowledges by ProviderXxxxxxxx's signature on this agreement that Provider understands that payment and satisfaction of each claim will be from Federal and State funds and that any false claims, statements or documents, or concealment of material fact, may be prosecuted under applicable Federal and State law. 10. Provider agrees to be individually responsible and accountable for the completion, accuracy, and validity of all claims submitted, including claims submitted for Provider by other parties. Provider further agrees to not make or cause to be made a claim, knowing the claim to be false, in whole or in part, by commission or omission or in any other respect contrary to the provisions of SDCL ch.22-45. 11. Provider agrees that claims for services and supplies rendered to Title XIX Non-Emergency Medical Transportation program medical assistance recipients shall not exceed the established program rates located in ARSD Chapter 67:16:25:07.04usual and customary charges by Provider to the general public for the same services and supplies. Provider further agrees to provide Medical Services and/or MFCU and/or HHS access to Provider's usual and customary billing practices. 12. Provider agrees to accept as payment in full the amounts paid in accordance with the reimbursement rates established reimbursement rates. The Provider understands that the pre-determined amount provided by the Title XIX Non-Emergency Medical Transportation program is an estimate based on the information provided and that a reimbursement determination will be made upon completion of the medical tripServices, receipt of all required forms and documentation and verification of covered services. The pre-determination process is not a guarantee of reimbursementincluding any authorized cost sharing as allowed by Medical Services. 13. Provider acknowledges the time limits for submission of Title XIX Non-Emergency that Medical Transportation claims as defined in ARSD Chapter 67:16:35:04. 14. Provider acknowledges that Finance/EBT Services is the payer of last resort (subject to certain exceptions) and acknowledges its obligation to pursue payment from all other liable parties. Provider further agrees that in the event Provider receives payment from the Title XIX Non-Emergency Medical Transportation medical assistance program in error or in excess of the amount properly due under the applicable rules and procedures, Provider will promptly notify Finance/EBT Medical Services and arrange for the return of any excess money so received. 1514. Provider agrees that failure to comply with any portion of this Provider Agreement will be good cause for termination of this agreement. 1615. Provider agrees that any improper submission of claims, or actions deemed an abuse of the Title XIX Non-Emergency Medical Transportation medical assistance program, or actions involving Title XIX Non-Emergency Medical Transportation medical assistance program abuse which result in administrative, civil or criminal liability, will be good cause for termination of this agreement. 1716. This agreement will be automatically terminated if Provider is convicted (including any form of suspended sentence) of any crime determined to be detrimental to the best interests of the Title XIX Non-Emergency Medical Transportation programAssistance Program, if Provider has been suspended or terminated from participation in Medicare, or if Provider's license is surrendered, lapsed, suspended, or revoked. 17. Provider agrees to accept payment from the medical assistance program via electronic funds transfer.

PROVIDER AGREES TO THE FOLLOWING. 1. Provider is currently a non-profit service organization as defined licensed to practice and in ARSD Chapter 67:16:25:01good standing in the State of South Dakota or in Provider's resident State. 2. Provider agrees to promptly notify Finance/EBT Medical Services if there is a change in Provider's name or address or address, if there is a change of ownership or corporate entity of Provider, or if Provider's license is revoked or suspended. Provider further agrees to supply all documentation necessary for the reimbursement of any outstanding claims upon termination from the Title XIX Non-Emergency Medical Transportation medical assistance program. 3. Provider agrees to comply with all Federal and State laws, regulations and rules applicable to Provider's participation in the Title XIX Nonmedical assistance program. Provider also agrees to abide by regulations and rules adopted during the term of the provider agreement pursuant to SDCL Chapter 1-Emergency Medical Transportation program, including program regulations located in ARSD Chapter 67:16:2526 or 5 USC §553. 4. Provider agrees to provide medically necessary goods and services as required by the recipient and only in the amount required by the recipient without discrimination on the grounds of age, race, color, sex, national origin, physical or mental disability, marital or economic status. 5. Provider agrees to keep complete and accurate medical and fiscal records that fully justify and disclose the extent of the services rendered and xxxxxxxx made under the Title XIX Non-Emergency Medical Transportation medical assistance program, and agrees to furnish Finance/EBT Medical Services and/or Medicaid Fraud Control Unit (MFCU) and/or Department of Health & Human Services (HHS), upon request and allow access to pertinent financial recordsrequest, such information regarding any payments claimed for providing these services. Provider agrees to obtain a written waiver of the physician-patient privilege and release of medical records from each patient for the purposes of allowing access to the pertinent patient records and facilities by Medical Services, MFCU and/or HHS. Access includes, but is not limited to, the examination, inspection, photocopying and/or auditing of any requested financial records. Provider understands that failure to submit or failure to retain adequate documentation for all services billed to the Title XIX Non- Emergency Medical Transportation medical assistance program may result in recovery of payments for medical transportation services not adequately documented, and may result in the termination or suspension of Provider from participation in the Title XIX Non- Emergency Medical Transportation medical assistance program, and may result in civil or criminal liability. 6. Provider acknowledges that by submitting a claim to the Title XIX Non-Emergency Medical Transportation medical assistance program, Provider certifies that the transportation expenses services were advanced to the program recipient medically necessary, were rendered prior to the submission of the claim to the Title XIX Non-Emergency Medical Transportation medical assistance program and that the services were rendered by Provider or incident to Provider's professional service by an employee, and in the case of an individual practitioner, under Provider's immediate personal supervision as permitted by the medical assistance program. 7. Provider agrees to allow Finance/EBT Medical Services and/or MFCU and/or HHS access to any and all financial records materials which may be deemed confidential by any regulatory or licensing agency, board or commission. 8. Provider agrees to submit claims in accordance with billing instructions and as required under any and all state regulations. 9. Provider agrees to submit claims that are true, accurate, and complete. Provider acknowledges by Provider's signature on this agreement that Provider understands that payment and satisfaction of each claim will be from Federal and State funds and that any false claims, statements or documents, or concealment of material fact, may be prosecuted under applicable Federal and State law. 10. Provider agrees to be individually responsible and accountable for the completion, accuracy, and validity of all claims submitted, including claims submitted for Provider by other parties. Provider further agrees to not make or cause to be made a claim, knowing the claim to be false, in whole or in part, by commission or omission or in any other respect contrary to the provisions of SDCL ch.22-45. 11. Provider agrees that claims for services and supplies rendered to Title XIX Non-Emergency Medical Transportation program medical assistance recipients shall not exceed the established program rates located in ARSD Chapter 67:16:25:07.04usual and customary charges by Provider to the general public for the same services and supplies. Provider further agrees to provide Medical Services and/or MFCU and/or HHS access to Provider's usual and customary billing practices. 12. Provider agrees to accept as payment in full the amounts paid in accordance with the reimbursement rates established reimbursement rates. The Provider understands that the pre-determined amount provided by the Title XIX Non-Emergency Medical Transportation program is an estimate based on the information provided and that a reimbursement determination will be made upon completion of the medical tripServices, receipt of all required forms and documentation and verification of covered services. The pre-determination process is not a guarantee of reimbursementincluding any authorized cost sharing as allowed by Medical Services. 13. Provider acknowledges the time limits for submission of Title XIX Non-Emergency that Medical Transportation claims as defined in ARSD Chapter 67:16:35:04. 14. Provider acknowledges that Finance/EBT Services is the payer of last resort (subject to certain exceptions) and acknowledges its obligation to pursue payment from all other liable parties. Provider further agrees that in the event Provider receives payment from the Title XIX Non-Emergency Medical Transportation medical assistance program in error or in excess of the amount properly due under the applicable rules and procedures, Provider will promptly notify Finance/EBT Medical Services and arrange for the return of any excess money so received. 1514. Provider agrees that failure to comply with any portion of this Provider Agreement will be good cause for termination of this agreement. 1615. Provider agrees that any improper submission of claims, or actions deemed an abuse of the Title XIX Non-Emergency Medical Transportation medical assistance program, or actions involving Title XIX Non-Emergency Medical Transportation medical assistance program abuse which result in administrative, civil or criminal liability, will be good cause for termination of this agreement. 1716. This agreement will be automatically terminated if Provider is convicted (including any form of suspended sentence) of any crime determined to be detrimental to the best interests of the Title XIX Non-Emergency Medical Transportation programAssistance Program, if Provider has been suspended or terminated from participation in Medicare, or if Provider's license is surrendered, lapsed, suspended, or revoked. 17. Provider agrees to accept payment from the medical assistance program via electronic funds transfer.

PROVIDER AGREES TO THE FOLLOWING. 1. Provider is currently a non-profit service organization as defined licensed to practice and in ARSD Chapter 67:16:25:01good standing in the State of South Dakota or in Provider's resident State. 2. Provider agrees to promptly notify Finance/EBT Medical Services if there is a change in Provider's name or address or address, if there is a change of ownership or corporate entity of Provider, or if Provider's license is revoked or suspended. Provider further agrees to supply all documentation necessary for the reimbursement of any outstanding claims upon termination from the Title XIX Non-Emergency Medical Transportation medical assistance program. 3. Provider agrees to comply with all Federal and State laws, regulations and rules applicable to Provider's participation in the Title XIX Nonmedical assistance program. Provider also agrees to abide by regulations and rules adopted during the term of this provider agreement pursuant to SDCL Chapter 1-Emergency Medical Transportation program, including program regulations located in ARSD Chapter 67:16:2526 or 5 USC §553. 4. Provider agrees to provide medically necessary goods and services as required by the recipient and only in the amount required by the recipient without discrimination on the grounds of age, race, color, sex, national origin, physical or mental disability, marital or economic status. 5. Provider agrees to keep complete and accurate medical and fiscal records that fully justify and disclose the extent of the services rendered and xxxxxxxx made under the Title XIX Non-Emergency Medical Transportation medical assistance program, and agrees to furnish Finance/EBT Medical Services and/or Medicaid Fraud Control Unit (MFCU) and/or Department of Health & Human Services (HHS), upon request and allow access to pertinent financial recordsrequest, such information regarding any payments claimed for providing these services. Provider agrees to obtain a written waiver of the physician-patient privilege and release of medical records from each patient for the purposes of allowing access to the pertinent patient records and facilities by Medical Services, MFCU and/or HHS. Access includes, but is not limited to, the examination, inspection, photocopying and/or auditing of any requested financial records. Provider understands that failure to submit or failure to retain adequate documentation for all services billed to the Title XIX Non- Emergency Medical Transportation medical assistance program may result in recovery of payments for medical transportation services not adequately documented, and may result in the termination or suspension of Provider from participation in the Title XIX Non- Emergency Medical Transportation medical assistance program, and may result in civil or criminal liability. 6. Provider acknowledges that by submitting a claim to the Title XIX Non-Emergency Medical Transportation medical assistance program, Provider certifies that the transportation expenses services were advanced to the program recipient rendered prior to the submission of the claim to the Title XIX Non-Emergency Medical Transportation medical assistance program and that the services were rendered by Provider or incident to Provider's professional service by an employee, and in the case of an individual practitioner, under Provider's immediate personal supervision as permitted by the medical assistance program. 7. Provider agrees to allow Finance/EBT and/or MFCU and/or HHS Medical Services access to any and all financial records materials which may be deemed confidential by any regulatory or licensing agency, board or commission. 8. Provider agrees to submit claims in accordance with billing instructions and as required under any and all state regulationsregulations distributed by Medical Services. 9. Provider agrees to submit claims that are true, accurate, and complete. Provider acknowledges by Provider's signature on this agreement that Provider understands that payment and satisfaction of each claim will be from Federal and State funds and that any false claims, statements or documents, or concealment of material fact, may be prosecuted under applicable Federal and State law. 10. Provider agrees to be individually responsible and accountable for the completion, accuracy, and validity of all claims submitted, including claims submitted for Provider by other parties. Provider further agrees to not make or cause to be made a claim, knowing the claim to be false, in whole or in part, by commission or omission or in any other respect contrary to the provisions of SDCL ch.22-45. 11. Provider agrees that claims for services and supplies rendered to Title XIX Non-Emergency Medical Transportation program medical assistance recipients shall not exceed the established program rates located in ARSD Chapter 67:16:25:07.04usual and customary charges by Provider to the general public for the same services and supplies. Provider further agrees to provide Medical Services and/or MFCU and/or HHS access to Provider's usual and customary billing practices. 12. Provider agrees to accept as payment in full the amounts paid in accordance with the reimbursement rates established reimbursement rates. The Provider understands that the pre-determined amount provided by the Title XIX Non-Emergency Medical Transportation program is an estimate based on the information provided and that a reimbursement determination will be made upon completion of the medical tripServices, receipt of all required forms and documentation and verification of covered services. The pre-determination process is not a guarantee of reimbursementincluding any authorized cost sharing as allowed by Medical Services. 13. Provider acknowledges the time limits for submission of Title XIX Non-Emergency Medical Transportation claims as defined in ARSD Chapter 67:16:35:04. 14. Provider acknowledges that Finance/EBT is the payer of last resort (subject to certain exceptions) and acknowledges its obligation to pursue payment from all other liable parties. Provider further agrees that in the event Provider receives payment from the Title XIX Non-Emergency Medical Transportation medical assistance program in error or in excess of the amount properly due under the applicable rules and procedures, Provider will promptly notify Finance/EBT Medical Services and arrange for the return of any excess money so received. 1514. Provider agrees that failure to comply with any portion of this Provider Agreement will be good cause for termination of this agreement. 1615. Provider agrees that any improper submission of claims, claims or actions which may be deemed as an abuse of the Title XIX Non-Emergency Medical Transportation program, medical assistance program or actions involving Title XIX Non-Emergency Medical Transportation program which result medical assistance abuse which result results in administrative, conviction of civil or criminal liability, money penalties will be good cause for termination of this agreement. 1716. This agreement will be automatically terminated if Provider is convicted (including any form of a criminal offense related to participation in the medical assistance program, if Provider has been suspended sentence) of any crime determined to be detrimental to the best interests of the Title XIX Non-Emergency Medical Transportation programor terminated from participation in Medicare, or if Provider's license is suspended or revoked.