HomeMy WebLinkAboutAgreements/Contracts - GRIS (002)K20-093
AMENDMENT to
AMERIGROUP WASHINGTON, INC.
PARTICIPATING PROVIDER AGREEMENT
THIS AMENDMENT TO PARTICIPATING PROVIDER AGREEMENT by and
between Amerigroup Washington, Inc. ("AMERIGROUP") and Grant County ("Provider"),
is effective upon the date of complete execution.
RECITALS:
A. AMERIGROUP and Provider are parties to that certain Participating Provider
Agreement for the administration of the Foundational Community Supports Program ("FCS"), as
amended from time to time (the "Agreement").
B. AMERIGROUP and Provider wish to amend the Agreement as set forth herein.
AGREEMENT:
NOW, THEREFORE, for good and valuable consideration, the receipt and sufficiency of
which is hereby acknowledged, the parties agree as follows.
1. The Agreement is amended to delete in its entirety Attachment A (Supported
Employment Services/Supported Housing Services Medicaid Reimbursement) from the
Agreement and replace it with a new Attachment A, which is attached hereto and incorporated
herein.
2. Except as expressly modified herein, nothing contained in this Amendment shall,
or shall be construed to, modify, alter or amend the Agreement. The parties hereto hereby affirm
the Agreement, except as expressly modified herein.
Amd by Mutual
IN WITNESS WHEREOF, the parties hereto have caused this Amendment to be duly executed.
AMERIGROUP WASHINGTON, INC
By:
[Name]
[Title]
[Date]
PR j ER:.
Cindy Carter, hair
L2 ajS '::�D
To or, Vice Chair
Richard Stevens, Member
T:
(.p — a- 3 - 2 0 A
ra J Vasquez
of the Board
Amd by Mutual
ATTACHMENT A
SUPPORTED EMPLOYMENT SERVICES/SUPPORTED HOUSING SERVICES
MEDICAID REIMBURSEMENT
Amd by Mutual
Name According to W-9 Form, with d/b/a: Grant County dba Grant Integrated Services
Federal Tax Identification Number: 91-6001319
ATTACHMENT A
AMERIGROUP Washington, Inc.
SUPPORTED EMPLOYMENT SERVICES / SUPPORTIVE HOUSING SERVICES
MEDICAID REIMBURSEMENT
Amerigroup shall compensate Provider for Covered Services provided to Covered Persons, subject
to all terms and conditions of this Agreement, benefit design, coordination of benefits (COB),
applicable authorization requirements, applicable coinsurance, program eligibility and applicable
Amerigroup's Provider Manual, in an amount equal to the lesser of Eligible Charges or the amounts
shown below unless otherwise specified.
Section I: Reimbursement
For Dates March 31. 2020 through June 30. 2020
Service Description
Billing Code
Rate
Method
Supported employment, per 15
HCPCS Code H2O23
$33
Per Service
minutes
HCPCS Code H2O25
$27
Per Service
Ongoing support to maintain
HCPCS Code H2O25
$33
Per Service
employment, per 15 minutes
Supportive housing, per diem
HCPCS Code H0043
$137
Per Diem
Fnr nntPc .Lily O1. 2020 Forward
Service Description
Billing Code
Rate
Method
Supported employment, per 15
minutes
HCPCS Code H2O23
$27
Per Service
Ongoing support to maintain
employment, per 15 minutes
HCPCS Code H2O25
$27
Per Service
Supportive housing, per diem
HCPCS Code H0043
$112
Per Diem
1. All appropriate modifiers must be used in accordance with standard billing guidelines, if
applicable.
2. Documentation shall be maintained to reflect date of service, length of service, number of units
and type of activity.
WA TPA Supported Employment —Supportive Housing Services
Rev.05/19/20
3. To participate, Provider shall comply and remain in accordance with the guidelines set forth on
Appendix A, as well as with WAC 182-559-200.
Section II: Notes
All services billed by Provider will be submitted on CMS -1500 (or its successor) forms or
corresponding electronic format. Amerigroup makes available Availity LLC as a central gateway
for electronic data interchange (EDI) transactions for authorized services.
2. Eligible Charges are those charges billed by the Provider subject to conditions and requirements
which make the service eligible for reimbursement. Eligibility for reimbursement of the service
is dependent upon application of the following conditions and requirements: Covered Person
program eligibility, provider program eligibility, benefit coverage, authorization requirements,
provider manual guidelines, Amerigroup administrative, clinical and reimbursement policies,
and code editing logic. The allowed amount reimbursed for the eligible charge is based on the
applicable fee schedule or contracted/negotiated rate after application of coinsurance, co-
payments, deductibles, and coordination of benefits. Amerigroup will not reimburse provider for
services or items the provider receives and/or provides free of charge.
WA TPA Supported Employment —Supportive Housing Services
Rev.05/19/20