Foster Home Medicaid Provider Enrollment Agreement



Child Foster Home Medicaid Provider Enrollment Application and Agreement (PEA)This PEA sets forth the conditions and agreements for being enrolled as a Child Foster Home provider (Provider) with the State of Oregon Department of Human Services (DHS), Office of Developmental Disabilities (ODDS), and to receive a provider number. The provider number is required prior to receiving authorization to provide services to Medicaid-eligible children with intellectual or developmental disabilities in Oregon home and community-based settings and to receive payment for Medicaid services delivered by Provider. Payment for services is made using federal Medicaid and state funds. Complete this PEA in its entirety. If the answer is “none” or “n/a” indicate that in the section.Section A ― Child Foster Home informationChild foster home (CFH) street address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code + 4: FORMTEXT ?????County: FORMTEXT ?????CFH phone number: FORMTEXT ?????Number of beds: FORMTEXT ?????Mailing address (if different or n/a): FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code + 4: FORMTEXT ?????CFH email address: FORMTEXT ?????CFH fax number: FORMTEXT ?????Provider number: FORMTEXT ?????Name(s) listed on CFH certificate: FORMTEXT ?????Type of provider enrollment action requested (must choose one): FORMCHECKBOX New enrollment FORMCHECKBOX Renewal or re-enrollment, provider #: FORMTEXT ????? FORMCHECKBOX Revalidation (only when requested by DHS), provider #: FORMTEXT ????? FORMCHECKBOX Physical address (site location) change, old provider #: FORMTEXT ????? FORMCHECKBOX eXPRS respite care enrollment (71-837)Type of child foster home certification (must choose one): FORMCHECKBOX Child foster home certified by the Office of Developmental Disability Services and governed by Oregon Administrative Rules (OAR) Chapter 411, Division 346. (71-703) FORMCHECKBOX Child foster home certified by Child Welfare and governed by OAR Chapter 413, Division 200. (71-704)Section B ― Provider information (certificate holder)Disclosure of Social Security numbers is required pursuant to 42 USC 405(c)(2)(C)(i) for the purpose of establishing identification, 42 CFR 455.104 for the purpose of exclusion verification, and 26 CFR 301.6109-1 for the purpose of reporting tax information. DHS will report information to the Internal Revenue Service (IRS) and the Oregon Department of Revenue under the name and Social Security number (SSN) of the first Provider/Certificate holder listed below.(Provider/Certificate holder)Last name (as known by IRS): FORMTEXT ?????First name (as known by IRS): FORMTEXT ?????MI: FORMTEXT ?????Title: FORMTEXT ?????Street address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code + 4: FORMTEXT ?????Social Security number (SSN): FORMTEXT ?????Date of birth: FORMTEXT ?????Home phone number: FORMTEXT ?????Percentage of CFH ownership: FORMTEXT ?????%Email address: FORMTEXT ?????Do you live in the foster home full-time as your primary residence? FORMCHECKBOX Yes FORMCHECKBOX NoAre you related to any other co-provider/co-certificate holder listed on this application? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how are you related (spouse, parent, child, sibling)? FORMTEXT ?????Have you been convicted of a criminal offense related to your involvement in any program under Medicare, Medicaid, CHIP or any other DHS program? FORMCHECKBOX Yes FORMCHECKBOX NoDo you have any other DHS provider numbers (e.g. Personal Support Worker, etc.)? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please list all provider names and numbers. FORMTEXT ?????Co-provider/Co-certificate holder (if applicable)Last name (as known by IRS): FORMTEXT ?????First name (as known by IRS): FORMTEXT ?????MI: FORMTEXT ?????Title: FORMTEXT ?????Street address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code + 4: FORMTEXT ?????Social Security number (SSN): FORMTEXT ?????Date of birth: FORMTEXT ?????Home phone number: FORMTEXT ?????Percentage of CFH ownership: FORMTEXT ?????%Email address: FORMTEXT ?????Does co-provider live in the foster home full-time as their primary residence? FORMCHECKBOX Yes FORMCHECKBOX NoIs co-provider related to any other provider/certificate holder or co-provider / co-certificate holder listed on this application? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how is co-provider related (spouse, parent, child, sibling)? FORMTEXT ?????Has co-provider been convicted of a criminal offense related to their involvement in any program under Medicare, Medicaid, CHIP or any other DHS program? FORMCHECKBOX Yes FORMCHECKBOX NoDoes co-provider have any other DHS provider numbers (e.g. Personal Support Worker, etc.)? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please list all provider names and numbers. FORMTEXT ?????Additional co-providers/co-certificate holders (if applicable)Last name (as known by IRS): FORMTEXT ?????First name (as known by IRS): FORMTEXT ?????MI: FORMTEXT ?????Title: FORMTEXT ?????Street address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code + 4: FORMTEXT ?????Social Security number (SSN): FORMTEXT ?????Date of birth: FORMTEXT ?????Home phone number: FORMTEXT ?????Percentage of CFH ownership: FORMTEXT ?????%Email address: FORMTEXT ?????Does co-provider live in the foster home full-time as their primary residence? FORMCHECKBOX Yes FORMCHECKBOX NoIs co-provider related to any other provider/certificate holder or co-provider/co-certificate holder listed on this application? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, how is co-provider related (spouse, parent, child, sibling)? FORMTEXT ?????Has co-provider been convicted of a criminal offense related to their involvement in any program under Medicare, Medicaid, CHIP or any other DHS program? FORMCHECKBOX Yes FORMCHECKBOX NoDoes co-provider have any other DHS provider numbers (e.g. Personal Support Worker, etc.)? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please list all provider names and numbers. FORMTEXT ?????AgreementThis Provider Enrollment Agreement, hereinafter referred to as the Agreement, sets forth the conditions for (1) being enrolled with the State of Oregon Department of Human Services (DHS) as a foster home Provider for children with intellectual or developmental disabilities; and (2) receiving Medicaid payment for services provided within a foster home. This Agreement is valid for the term of Provider's current foster home certification and shall remain in effect during the term of the certification unless terminated earlier in writing in accordance with the terms of this Agreement.1.Provider understands and agrees that all information submitted in this Agreement is true and accurate. Information disclosed by the Provider is subject to verification. Any deliberate omission, misrepresentation or falsification of any information contained in this Agreement or contained in any communication supplying information to DHS, may be punished by administrative law, criminal law or both, including, but not limited to, revocation of the Provider's certification to operate a child foster home; refusal to issue a DHS Provider number; revocation of the DHS Provider number; and recovery of any overpayments.2.Provider must notify DHS of any changes to the information contained in this Agreement within thirty (30) days of the date of the change. Provider understands and agrees DHS may terminate this Agreement if it determines that the provider did not fully and accurately make any disclosure required in this Agreement or if the Provider fails to notify DHS of any changes within thirty (30) days.3.Certification and Medicaid enrollment applies to the Provider and Co-provider identified above. Provider and Co-provider must only delegate care and supervision responsibilities in accordance with the alternate caregiver provisions set forth in OAR Chapter 411, Division 346. When using an alternate caregiver as defined in OAR 411-346-0110, the Provider and Co-provider agree to fully comply with the following requirements: (1) Background checks for alternate caregivers as outlined in OAR 411-346-0150; (2) Standards and practices for alternate caregivers as outlined in OAR 411-346-0190; (3) All applicable provisions under OAR Chapter 411, Division 346; and confirm that the alternate caregivers are not listed on the Office of Inspector General (OIG) or the System Award Management (SAM) exclusion lists.4.Provider shall, upon reasonable request by DHS, Oregon Health Authority (OHA), Oregon Medicaid Fraud Unit, Oregon Secretary of State’s Office, Center for Medicare and Medicaid Services or their agents, or designated contractors, grant immediate access to review and copy any and all records relied upon by Provider or Co-Provider(s) in support of care and services provided under this Agreement. The term “immediate access” means access to records at the time the written request is presented to the Provider.5.Provider agrees they are not in violation of any Oregon Tax Laws. For purposes of this certification, “Oregon Tax Laws” means a state tax imposed by Oregon Revised Statutes (ORS) 320.005 to 320.150 and 403.200 to 403.250 and ORS chapters 118, 314, 316, 317, 318, 321, and 323, and the elderly rental assistance program under ORS 310.630 to 310.706 and local taxes administered by the Department of Revenue under ORS 305.620.6.Provider is not subject to backup withholding under any of the following conditions: Provider is exempt from backup withholding; Provider has not been notified by the IRS that Provider is subject to backup withholding as a result of a failure to report all interest or dividends; or the IRS has notified Provider that Provider is no longer subject to backup withholding.7.Provider is not included on the list titled “Specially Designated Nationals and Blocked Persons” maintained by the Office of Foreign Assets Control of the United States Department of the Treasury and currently found at: shall at all times be qualified, professionally competent and actively certified to perform work under this Agreement.9.Provider agrees to fully comply with the following: (1) all applicable certification and regulatory requirements as set forth by federal and state statutes, regulations, and rules; (2) OAR Chapter 411, Division 346, and all Oregon statutes, rules, and regulations applicable to the provider’s scope of service; and (3) program-specific rules for the type of home for which provider is certified.10.Provider understands and agrees that prior authorization must be granted by the local Community Developmental Disability Program (CDDP) before placement of any client and that payment will not be issued if prior authorization was not granted.11.Provider understands that all clients served in the foster home whose placements are funded by the Office of Developmental Disability Services are entitled to the Home and Community-based Freedoms and Protections under OAR Chapter 411, Division 004. Furthermore, Provider understands and agrees to fully comply with Home and Community-Based Freedoms and to fully comply with the Home and Community-based Freedoms and Protections against involuntary exits as outlined in OAR 411-346-0180(4).12.Provider agrees to provide the care and services necessary to ensure the health, safety and well-being of clients in the Provider's home and to maximize clients' ability to function at the highest level of independence as possible. Provider understands and agrees payment may be denied or subject to recovery if care or services were not authorized or not provided in accordance with the requirements specified in this Agreement.13.Provider will receive notification of individual client service rates. Provider agrees to accept the rate authorized by DHS as payment in full. Provider is not to charge the client, or any person responsible for the client, any additional amounts beyond the DHS-determined client service contribution. Payment for ongoing services shall be processed after the end of the month in which service was provided. Payment for services that have ended shall be processed after the end of services. Provider understands and agrees payment cannot be made to any individual or entity that has been excluded from participation in federal or state programs, or that employs or is managed by excluded individuals or entities (ORS 443.004). As a condition of payment, Provider must meet and maintain compliance with the Provider Rules, OAR 407-120-0300 through 407-120-0380 and 407-120-1505.14.Provider may terminate this Agreement at any time by submitting a written notice in person or by certified mail with the specific date on which termination will take place. Notification must be submitted a minimum of sixty (60) days prior to the termination date. Termination by the Provider must be sent to the local CDDP office and to DHS. Provider must also submit appropriate and timely notice to all residents affected by this termination as outlined in the applicable program specific rules.15.Department of Human Services (DHS) may terminate this Agreement at any time by submitting a notice in person or by certified mail with the specific date on which termination will take place. 16.Provider understands and agrees Provider is not employed by any division of DHS, any Brokerage or CDDP, and shall not for any purposes be deemed an employee of the State of Oregon except as set forth in ORS 443.733 (collective bargaining). Provider and any Co-providers are solely responsible for their acts or omissions and shall perform all work as an independent contractor being responsible to determine the appropriate means and manner of performance.17.Unless liability is otherwise established by law, Provider shall indemnify and defend the State of Oregon, any Oregon county, Area Agency on Aging, Community Developmental Disability Program, their respective agencies and their officers, employees and agents from and against all claims, suits, actions, losses, damages, liabilities, costs and expenses of any nature whatsoever arising out of, or relating to the acts or omissions of Provider or Co-provider(s) under this Agreement.18.Provider shall not disclose any information concerning individuals served under this Agreement to third-parties except as allowed by law or with the prior written consent of the Medicaid-eligible individual, their legal guardian, or other person acting with power of attorney for the Medicaid-eligible individual and in compliance with all applicable state and federal law requirements.19.DHS payment for any service provided under this Agreement is payment in full. Provider and Co-provider(s) will not make any additional charge to Medicaid-eligible individuals served under this Agreement except when specifically allowed by DHS rules. Payment of claims will be for services provided to Medicaid-eligible individuals in accordance with all applicable provisions of state and federal statutes, rules and regulations governing the reimbursement of services under Medicaid, as those laws, rules and regulations may be adopted or amended from time to time. By accepting payment, Provider and Co-providers certify compliance with all applicable DHS rules. Any falsification in connection with the receipt of payment for services may be prosecuted under federal and state law.20.Any overpayment made by DHS may be recouped by DHS or OHA as authorized by law including, but not limited to, withholding of future payments to Provider and Co-provider(s).21.Provider and Co-provider(s) shall keep such records as are necessary to fully disclose the specific care and services provided to Medicaid-eligible individuals served under this Agreement for which reimbursement is claimed, in compliance with the applicable rules, including any requests received from any state or federal agency responsible for administration or oversight of the program. Provider and Co-provider(s) are responsible for the completion and accuracy of financial and service records and all other documentation regarding the specific care and services for which payment has been requested.22.Provider shall retain and keep accessible all records for the longer of six years following final payment and termination of this Agreement, or any period as required by applicable law, including retention schedules set forth in OAR Chapter 166, or until the conclusion of any audit, controversy, or litigation arising out of, or related to this this Agreement.23.Provider has fully read, understands and agrees to comply with the terms and conditions set forth in this Agreement.By signing below, provider declares that he or she understands and agrees that violation of any of the terms and conditions of this Agreement constitute grounds for termination of this Agreement and may be grounds for sanction as provided by Oregon statute, administrative rule or this Agreement. FORMTEXT ?????Provider signatureDate FORMTEXT ?????Co-provider signature(s)DateLocal licensing authority use only FORMCHECKBOX OIG verified FORMCHECKBOX OSBN verified FORMCHECKBOX GSA (SAM) verified FORMCHECKBOX CNA Registry verified FORMCHECKBOX Approved background check FORMCHECKBOX Business Registry verifiedCFH certification start date: FORMTEXT ?????CFH certification end date: FORMTEXT ?????DHS staff or designee signature and title: FORMTEXT ?????Date: FORMTEXT ????? ................
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