Article I For the purposes of this agreement A. The term "Secretary" means the Secretary of Health, Education, and Welfare or his delegate. B. The term "Act" means the Social Security Act, as amended from time to time. C. The term "provider of services" means an institution, facility, or agency so designated on a list furnished to the Intermediary by the Secretary as a participating provider of services. D. The term "non-participating provider of services" means an institution, facility, or agency so designated by the Secretary. E. The term "emergency hospital" means an institution which the Secretary has determined to be eligible for payments as authorized by sections 1814 (d) (1), 1814(f), and 1835(b)(1) of the Act. F. The term "eligible individual" means an individual to whom payment may be made pursuant to sections (i) 1814 (d) (2), (ii) 1832 (a) (1) for medical and other health services described in 1861(s) (2) (B) and (C), 3 through 9 inclusive, when furnished by a non-participating provider of services, (iii) 1835(b) (2) and 1835(c) of the Act. G. The term "covered services" means the items or services, for which payment may be made under sections 1812 (a) and 1832 (a) of the Act except items or services for which payments may not be made by reason of section 1862 of the Act. H. The term "General Instructions" means manuals and written instructions of general application to Carriers or Fiscal Intermediaries issued by the Secretary pursuant to the Act in respect to matters covered by this agreement. I. For the purposes of this agreement, the term "subcontract" means any contract, agreement, purchase order, or lease (including leases of real property) to obtain space, supplies, equipment, or services under this agreement; the term "subcontractor" means any holder of one or more subcontracts. J. The term "Federal Procurement Regulations (FPR)”, as used in this agreement, means those Parts of the Federal Procurement Regulations to which reference is made hereinafter, as in effect on the effective date of this agreement. Article II FUNCTIONS AND DUTIES TO BE PERFORMED BY THE PLAN The Plan shall: A. Make determinations as to whether the services provided an individual are covered services and of the amounts of payments required to be made to each provider of services, to each non-participating provider of services, to each emergency hospital, and to each eligible individual in accordance with the provisions of the Act, Regulations promulgated pursuant thereto, and General Instructions. B. Receive, disburse, and account for funds in making such payments. C. Make audits of the records of providers of services and of emergency hospitals. D. Assist providers of services in the development of procedures relating to utilization practices and make studies of the effectiveness of such procedures, including the appraisal and evaluation of the results of provider utilization review activity and recommendations for necessary changes in provider utilization practices and procedures; and assist in the application of safeguards against unnecessary utilization of services. E. Process and pay claims for services found by the Secretary to be emergencies, and for services rendered by hospitals outside of the United States, as authorized by sections 1814 (d), 1814(f), and 1835(b) of the Act. F. With respect to the functions of the Plan contained in this agreement, serve as a center for and communicate to providers of services information or instructions of the Secretary, and serve as a channel of communications from such providers of services to the Secretary and the Intermediary. G. Assist any institution, facility, or agency to qualify as a provider of services and to establish and maintain fiscal records for purposes of Title XVIII of the Act. H. Make such Medicare management studies as may be approved by the Secretary and Intermediary to insure the effective performance of this agreement. I. Participate in or perform statistical and research studies as the Secretary and Intermediary may request or approve. These studies may include, but shall not be limited to, experimentation studies conducted pursuant to section 222 of P.L. 92-603 and section 402 of the Social Security Amendments of 1967, as amended. Notwithstanding these provisions, the Secretary may enter directly into a contract with any Plan for participation in any of the foregoing experimentation studies, in which event, the Secretary will forward to the Intermediary a copy of the protocol of any such experimentation study, and, to the extent that any function or duty of the Intermediary set forth in this Article is inconsistent with the experimentation study, the Secretary shall waive performance of such function or duty by the Intermediary. The allowability of any costs incurred by the Intermediary in the discontinuance of performance of any function or duty waived by the Secretary shall be governed by the provisions of section B of Article XIII applicable to termination costs. J. Notwithstanding any provision of this agreement, as approved by the Secretary, enter into arrangements directly with a Professional Standards Review Organization for purposes of implementation of Title XI of the Act. The Secretary shall provide the Intermediary and the Plan with a notice of waiver of otherwise applicable functions and duties when such functions and duties have been assumed by a Professional Standards Review Organization in accordance with Title XI of the Act. K. In pursuance of its primary responsibility under this agreement to receive and review claims from providers of services, non-participating providers of services, emergency hospitals and eligible individuals, receive and review such claims and send such claim forms directly to the Secretary, and take corrective action with respect to rejected claim forms. L. Shall prepare and present the Plan's position to the Provider Reimbursement Review Board in those instances where a provider of services, serviced by the Plan, requests a hearing by the Board pursuant to the provisions of 20 CFR - Subpart R (Section 401.1801 et seq.) with such assistance incident to the particular case as the Plan may request from the Intermediary. M. Establish and maintain such procedures as the Intermediary and the Secretary may approve for the review and reconsideration of determinations under which payment to an eligible individual or provider of services on behalf of an individual for services furnished him has been denied or the amount of such payment is in controversy. N. Upon inquiry, assist individuals with respect to matters pertaining to this agreement. O. Receive rejected claim forms and take corrective action with respect thereto. P. Perform such duties as may be necessary to carry out the provisions of this agreement and such other functions as may be agreed upon by the Secretary, Intermediary, and the Plan. Article III FUNCTIONS AND DUTIES TO BE PERFORMED BY THE INTERMEDIARY The Intermediary shall: A. Furnish the Plan with a list of providers of services and keep such list current by advising the Plan on a timely basis of additions and deletions to such list as provided in Article XVII. B. Upon inquiry by the Plan, obtain from the Secretary and furnish the Plan with the names, eligibility and claims history of individuals entitled to services under Title XVIII of the Act, and other information pertinent to the administration of this agreement. C. Use its private wire system in the administration of this agreement. D. Refer rejected claims to the Plan for investigation and appropriate corrective action. E. Furnish the Plan information and instructions received from the Secretary and communicate to the Secretary information and requests from the Plan. F. Upon inquiry by the Plan, cite authority for an undertaking required of the Plan by the Intermedi ary. G. Waive performance of any function or duty as provided in paragraphs I and J of Article II. H. Provide funds to the Plan for the Plan's cost of administering this agreement as provided in Article VI. I. Furnish the Plan with the names of the individuals, together with the scope of their authority, authorized to act for the Intermediary in the administration of this agreement and a list of positions together with the scope of their authority, authorized to act for the Secretary in the administration of the agreement between the Intermediary and the Secretary. Article IV PAYMENT FOR COVERED SERVICES A. The Plan shall pay, to the extent that funds therefor have been advanced to it pursuant to Article V hereof: 1. Providers of services, on an interim and final basis, in amounts determined in accordance with the Act, the Regulations promulgated pursuant thereto, and General Instructions. 2. Emergency hospitals which have made the election provided by section 1814(d) (1) (C) of the Act on an interim and final basis in amounts determined in accordance with the provisions of the Act, Regulations promulgated pursuant thereto, and General Instructions. 3. Eligible individuals in accordance with the Act, the Regulations promulgated pursuant thereto, and General Instructions. 4. Non-participating providers of services and those emergency hospitals which have not made the election provided by section 1814 (d) (1) (C) of the Act when the eligible individual has assigned his right to payment in accordance with the Act, the Regulations promulgated pursuant thereto, and General Instructions. B. If, after payment has been made to or on behalf of an eligible individual, it is determined that more or less than the correct amount has been paid by the Plan, the Plan shall undertake to recover the overpayment or adjust the underpayment except that the Plan shall not initiate court proceedings to recover any overpayments. If within such period as may be specified in Regulations or General Instructions, the Plan is unable to recover the overpayment or adjust the underpayment, the Plan shall so notify the Intermediary after such period has expired. C. No individual designated as a certifying officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payments certified by him pursuant to this agreement. No disbursing officer shall, in the absence of gross negligence or intent to defraud the United States, be liable with respect to any payments made by him under this agreement if it was based upon a voucher signed by a designated certifying officer. Neither the Intermediary nor the Plan shall be liable to the United States for payments referred to in the two preceding sentences. D. No certifying officer or disbursing officer shall be held liable for any amounts certified or paid by him to any provider of services, non-participating provider of services, emergency hospital, or eligible individuals for covered services under this agreement where adjustment or recovery of such amount (as authorized by section 1870 of the Act) is waived pursuant to section 1870(c) or where adjustment authorized under section 1870(b) is not completed prior to the death of all persons against whose benefits such adjustments are authorized. Article V ADVANCE OF FUNDS AND TRANSFER OF FUNDS THROUGH LETTER OF CREDIT A. The Secretary shall provide for an advance of funds by a letter of credit to the Plan or its designated commercial bank as provided for in this paragraph to authorize the withdrawal of funds from the United States Treasury and a transfer of such funds to the Federal Health Insurance Benefits Account established as provided in paragraph E of this Article. Each letter of credit will authorize either the Plan or its commercial bank to process payment vouchers to be presented to the Federal Reserve Bank for credit to the Federal Health Insurance Benefits Account. The Plan's commercial bank will be authorized to process payment vouchers when it is advantageous to the Government. Where the Plan's commercial bank is not authorized to process payment vouchers, the Plan will be authorized to process payment vouchers, drawing on the Social Security Trust Funds through its bank against a Federal Reserve Bank. B. Funds withdrawn and transferred as described in the preceding paragraph shall be used only: 1. to provide funds to make reimbursement to providers of services or others as specified in Article IV to whom the Plan is authorized to make reimbursement under this agreement, and 2. to establish and maintain the Federal Health Insurance Time Account if established as provided in paragraph E of this Article. C. The letter of credit will specify a maximum monthly amount which may be withdrawn during each month based on estimates by the Secretary of the amounts needed to make such payments. Amounts available for withdrawal but not withdrawn in any month will not carry over to the following month. However, the Plan, or its bank shall make withdrawals only to the extent that funds are needed to meet current payments and expenditures under paragraph B of this Article. If the amount specified in the letter of credit is not sufficient to meet current payments and expenditures under paragraph B of this Article, the letter of credit shall be revised promptly by the Secretary. If a difference arises regarding the proper amount of an advance or of a withdrawal provided for in this paragraph, the Plan's representatives may participate in discussions with the Secretary for the purpose of resolving such difference. D. The Plan may forward payments to providers of services and others furnishing covered services together with payments for other obligations of the Plan which may be identified on the same listing or report to the provider or others. The Plan shall submit a monthly statement to the Intermediary simultaneously with a copy to the Secretary, showing the disbursements made from the Federal Health Insurance Benefits Account as provided for in paragraph E of this Article. E. All funds withdrawn through the letter of credit, as specified in paragraph A of this Article, shall be designated for deposit only in Federal Health Insurance Benefits Accounts of a member bank or banks of the Federal Reserve System or any insured bank within the meaning of the Act creating the Federal Deposit Insurance Corporation (Act of August 23, 1935, 49 Stat. 648), as amended (12 U.S.C. 264) and be kept separate and apart from the Plan's general or other funds. The Plan is also authorized to establish a Federal Health Insurance Time Account in conjunction with this agreement. Both the Federal Health Insurance Benefits Account and the Federal Health Insurance Time Account, if estab lished, shall be so designated as to indicate clearly to the bank the special character and purpose of such funds. The funds from the Federal Health Insurance Benefits Account shall be used by the Plan exclusively for making payments as specified in paragraph B of this Article. The Plan shall submit monthly statements to the Secretary and the Intermediary showing the disbursements made from such Federal Health Insurance Benefits Account. F. The Plan shall furnish to the Secretary and the Intermediary copies of the agreement(s) executed with each bank in which the Federal Health Insurance Benefits Account or the Federal Health Insurance Time Account is established. Such agreement shall be executed on forms prescribed by the Secretary and shall contain a provision that the United States shall have lien upon the credit balance in such Federal Health Insurance Benefits Account or the Federal Health Insurance Time Account to secure repayment of all funds advanced under this agreement. Such lien shall be superior to any lien or claim of the bank with respect to such amounts. In the interest of effective and efficient administration of this agreement the Secretary may, after consultation with the Plan and the Intermediary, direct the Plan in writing to cause termination of the agreement(s) with the bank after 120 days notice to the bank and to have established the Federal Health Insurance Benefits Account and the Federal Health Insurance Time Account, if established, in another bank meeting the standards referred to in paragraph E of this Article. When it is considered advantageous to the Government, the Secretary may also direct in writing the establishment of the “checks paid" method of financing in accordance with Department of the Treasury, Circular No. 1075 (third revision), 1973, Section 205.5(i). G. The Plan will draw its administrative expenses from the Intermediary, through the Intermediary's letter of credit, as established in Article V of the Intermediary's agreement with the Secretary. Funds so withdrawn by the Plan shall be used solely for the cost of administering this agreement as specified in Article VI herein. Article VI TRANSFER OF FUNDS, BUDGETS, AND REIMBURSEMENT A. The Plan shall submit to the Bureau of Health Insurance Regional Office and the Intermediary, at such time and in such form as the secretary may determine, a budget of its estimated administrative expenses for a period corresponding to the fiscal year period of the United States. Such budget shall be accompanied by supporting documents. Any questions concerning the Plan's budget shall be discussed by the Secretary and the Plan. The Plan may at any time submit appropriate amendments to such budget which reflect modifications in its cost estimates. B. The Secretary, acting through the Regional Representatives of the Bureau of Health Insurance of the Social Security Administration, and the Plan, by delegation of authority from the Intermediary, shall negotiate the amount of the annual budget, and amendments thereto, based on the amount submitted by the Plan in an amount calculated to pay the costs of administering the Plan's agreement. The Plan shall conduct these negotiations in accordance with the direction of the Intermediary with regard to any and all performance objectives agreed to by the Secretary and the Intermediary. After the negotiations between the Secretary and the Plan on the amount of the annual budget and any amendments thereto, the Secretary shall issue a notice to the Plan by July 1 (provided that the Plan has submitted its budget in accordance with paragraph A of this Article) specifying such budgeted amount. Such budgeted amount for the purpose of obligation of funds by the Secretary shall be a ceiling which the Plan may not exceed without prior approval of the Secretary or as subject to paragraph E. If there are any modifications to this agreement during its term, the budgeted amount shall be amended to 76-614 - 76 - 15 |