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AMENDMENT#8TO
BEACON FACILITY AGREEMENT
This eighth amendment ("Amendment") amends the Beacon Facility Agreement ("Agreement") entered into by Beacon Health
Options, Inc. ("Beacon") and County of Grant dba Grant Integrated Services ("Facility"). Unless otherwise defined herein, all
capitalized terms used in this Amendment shall have the same meaning as set forth in the Agreement.
WHEREAS, the Agreement permits amendments to the Agreement by Beacon and Facility; and
WHEREAS, Beacon and Facility desire to amend the Agreement to make certain changes to it.
NOW, THEREFORE, in consideration of the promises and mutual covenants contained herein and other good and valuable
consideration, the receipt and sufficiency of which is hereby acknowledged, the Agreement is hereby amended as follows:
1. All previous Exhibits funded by the contract between Beacon and Health Care Authority, except Exhibit A Facility
Location(s) & Practitioners, Services & Payment, are removed and replaced with the following effective July 1, 2020
a. Exhibit A -1.A4 NWRF Rate Schedule is removed in its entirety and replaced with Exhibit A -1.A8 NWRF Rate
Schedule.
b. Exhibit A -2.A4 NWSA Rate Schedule is removed in its entirety and replaced with Exhibit A -2.A8 NWSA Rate
Schedule.
c. Exhibit B -2.A4 Maximum Contract Amounts is removed in its entirety and replaced with Exhibit B -2.A8
Maximum Contract Amounts.
d. Exhibit B -4.A4 Crisis Program Provisions (Mobile Crisis and Designated Crisis Responder) is removed in its
entirety and replaced with Exhibit B -4.A8 Crisis Program Provisions (Mobile Crisis and Designated Crisis
Responder).
e. Exhibit B -8.A4 Washington State Health Care Authority Specific Provisions is removed in its entirety and
replaced with Exhibit B -8.A8 Washington State Health Care Authority Specific Provisions.
f. Exhibit B -10.A4 Mental Health Block Grant Program Provisions is removed in its entirety and replaced with
Exhibit B -10.A8 Mental Health Block Grant Program Provisions.
g. Exhibit B -11.A4 Substance Use Disorder Program Provisions is removed in its entirety and replaced with
Exhibit B -11.A8 Substance Use Disorder Program Provisions.
h. Addendum to B -11A.4 Mobile Outreach Team is removed in its entirety and replaced with Addendum to B-
11 A.8 Mobile Outreach Team.
I. Exhibit B -20.A4 ESSB 5883 Start Up Funds is removed in its entirety and replaced with Exhibit B -20.A8 ESSB
5883 Start Up Funds.
2. This Amendment shall be effective upon the date set forth by Beacon following signature by both Beacon and Facility.
3. Except as amended herein, all other terms and conditions of the Agreement shall remain in full force and effect without
modification.
Scope of work pursuant with contract terms between Beacon and Health Care Authority as dictated in contract
amendment dated July 1, 2020.
Facility: County of Grand dba Grant Integrated Services
BHO-F-COM-MA-MCD/1112015
(AG — VO STD FACILITY)
=RECEiVEDAmend 8 — PID 301052
Page 1 of 68
Address: 840 E. Plum, Moses Lake, WA 98837
NPI: 1689677833, 1982792537
BHO-F-COM-MA-MCDI11/2015 Amend 8 — PID 301052
(AG — VO STD FACILITY) Page 2 of 68
Intending to be legally bound, the parties have caused their authorized representatives to execute this Agreement
effective as of the date set forth by Beacon below.
County of Grant dba Grant Integrated Services:
Signature
9-V5.u0
Date
h *fAJx,
OCL CNS l /�
Print Name Title
Federal Tax Identification Number: 91.6001319
Address for Notice:
County of Grant dba Grant Integrated Services
PO Box 1057
Moses Lake, WA, 98837-0160
Beacon Health Options, Inc.:
Signature
Date
Print Name & Title
Address for Notice:
Beacon Health Options, Inc.
P.O. Box 989
Latham, NY 12110-6402
Attn: National Provider Network Operations
Please do NOT write below this line. For Beacon office use ONLY.
EFFECTIVE DATE: July 1, 2020
Negotiated by: Karen Black
Print Name
Contract Development Manager
Date Received by Beacon
Please check if included: ❑ ❑
BHO-F-COM-MA-MCD/11/2015 Amend 8 — PID 301052
(AG — VO STD FACILITY) Page 3 of 68
Exhibit A -1.A8
NWRF Rate Schedule
This Exhibit contain the service codes and billing rates that are allowed under the NWRF fund code. Following the Rate Schedule
is a table listing modifiers and their descriptions as well as a key to abbreviations used in the Rate Schedule.
Definitions
1. Payment Type:
a. Fee for Service (FFS): Claims submitted for health care payments, also known as the Fee for Service (FFS)
payment type, must be cleanly submitted within current Washington State Health Care Authority timely filing
requirements in the format outlined in this Rate Schedule.
b. Prepaid: Encounters submitted for health care reporting purposes, also known as the Prepaid payment type,
must be cleanly submitted to Beacon monthly by the 15th in the format outlined in this Rate Schedule.
Payment for services provided will be made according to the Payment Method identified in Exhibit B-2
Maximum Contract Amounts.
NWRF Rate Schedule.A8
Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per Unit
Allowed
Place of Service
Allowed
Payment
Code
A-1 NWRF
1
2
3
4
Billing Unit
POS
Dx
Type
99075
Medical Testimony
H9
ET
$0.01
1 Unit Per
Encounter
11, 12, 21, 23, 51,
53, 56, 99
MH, SU
Prepaid
03, 04, 06, 09, 11,
H0030
Behavioral Health
ET
HN
$0.01
1 Unit Per
12, 14, 15, 16, 21,
MH, SU
Prepaid
Hotline Service
Encounter
22, 23, 32, 51, 53,
56, `57, 99,13
03, 04, 06, 09, 11,
H0030
Behavioral Health
ET
$0.01
1 Unit Per
12, 14, 15, 16, 21,
MH, SU
Prepaid
Hotline Service
Encounter
22, 23, 32, 51, 53,
56, *57, 99,13
Self-help/peer
Multiple
02, 03, 04, 06, 09,
H0038
services - Per 15
ET
GT
$0.01
Units
11, 12, 14, 15, 16,
21, 22, 23, 32, 51,
MH, SU
Prepaid
minute unit
Allowed
53, 56, '57, 99, 13
Self-help/peer
Multiple
02, 03, 04, 06, 09,
H0038
services - Per 15
ET
HM
GT
$0.01
Units
11, 12, 14, 15, 16,
21, 22, 23, 32, 51,
MH, SU
Prepaid
minute unit
Allowed
53, 56, *57, 99, 13
Self-help/peer
Multiple
03, 04, 06, 09, 11,
H0038
services - Per 15
ET
HM
HK
$0.01
Units
12, 14, 15, 16, 21,
22 23, 32, 51, 53,
MH, SU
Prepaid
minute unit
Allowed
56, '57, 99, 13
Self-help/peer
Multiple
03, 04, 06, 09, 11,
H0038
services - Per 15
ET
$0.01
Units
12, 14, 15, 16, 21,
22 23, 32, 51, 53,
MH, SU
Prepaid
minute unit
Allowed
56, *57, 99, 13
Mental Health
02, 03, 04, 06, 09,
Services not otherwise
1 Unit Per
11, 12, 14, 15, 16,
H0046
specified -1 unit
ET
GT
$0.01
Encounter
21, 22, 23, 32, 51,
MH, SU
Prepaid
=<15mins; 1 per
53, 56, 57, 99,13
encounter
Mental Health
03, 04, 06, 09, 11,
Services not otherwise
1 Unit Per
12, 14, 15, 16, 21,
H0046
specified -1 unit
ET
HK
$0.01
Encounter
22, 23, 32, 51, 53,
MH, SU
Prepaid
=<15mins; 1 per
56,'57, 99,13
encounter
BHO-F-COM-MA-MCD/11/2015 Amend 8 - PID 301052
(AG - VO STD FACILITY) Page 4 of 68
Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per Unit
Allowed
Place of Service
Allowed
Payment
Code
A-1 NWRF
1
2
3
4
Billing Unit
POS
Dx
Type
Mental Health
02, 03, 04, 06, 09,
Services not otherwise
1 Unit Per
11, 12, 14, 15, 16,
H0046
specified -1 unit
ET
HM
GT
$0.01
Encounter
21, 22, 23, 32, 51,
MH, SU
Prepaid
=<15mins; 1 per
53, 56, *57, 99,13
encounter
Mental Health
03, 04, 06, 09, 11,
Services not otherwise
1 Unit Per
12, 14, 15, 16, 21,
H0046
specified -1 unit
ET
HM
HK
$0.01
Encounter
22, 23, 32, 51, 53,
MH, SU
Prepaid
=<15mins; 1 per
56, *57, 99,13
encounter
Mental Health
03, 04, 06, 09, 11,
Services not otherwise
1 Unit Per
12, 14, 15, 16, 21,
H0046
specified -1 unit
ET
HM
$0.01
Encounter
22, 23, 32, 51, 53,
MH, SU
Prepaid
=<15mins; 1 per
56, 57, 99,13
encounter
Mental Health
02, 03, 04, 06, 09,
Services not otherwise
1 Unit Per
11, 12, 14, 15, 16,
H0046
specified -1 unit
ET
HN
GT
$0.01
Encounter
21, 22, 23, 32, 51,
MH, SU
Prepaid
=<15mins; 1 per
53, 56, *57, 99,13
encounter
Mental Health
03, 04, 06, 09, 11,
Services not otherwise
1 Unit Per
12, 14, 15, 16, 21,
H0046
specified -1 unit
ET
HN
HK
$0.01
Encounter
22, 23, 32, 51, 53,
MH, SU
Prepaid
=<15mins; 1 per
56, *57, 99,13
encounter
Mental Health
03, 04, 06, 09, 11,
Services not otherwise
1 Unit Per
12, 14, 15, 16, 21,
H0046
specified -1 unit
ET
HN
$0.01
Encounter
22, 23, 32, 51, 53,
MH, SU
Prepaid
=<15mins; 1 per
56, 57, 99,13
encounter
Mental Health
03, 04, 06, 09, 11,
Services not otherwise
1 Unit Per
12, 14, 15, 16, 21,
H0046
specified -1 unit
ET
$0.01
Encounter
22, 23, 32, 51, 53,
MH, SU
Prepaid
=<15mins; 1 per
56, 57, 99,13
encounter
Crisis Intervention
Multiple
02, 03, 04, 06, 09,
H2011
Services, per 15
ET
GT
$0.01
Units
11, 12, 14, 15, 16,
21, 22, 23, 32, 51,
MH, SU
Prepaid
minute unit
Allowed
53, 56, *57, 99,13
Crisis Intervention
Multiple
03, 04, 06, 09, 11,
H2011
Services, per 15
ET
HK
$0.01
Units
12, 14, 15, 16, 21,
22 23, 32, 51, 53,
MH, SU
Prepaid
minute unit
Allowed
56, *57, 99,13
Crisis Intervention
Multiple
03, 04, 06, 09, 11,
H2011
Services, per 15
ET
$0.01
Units
12, 14, 15, 16, 21,
MH, SU
Prepaid
minute unit
Allowed
22 23, 32, 51, 53,
56, *57, 99,13
Crisis Intervention
Multiple
02,03, 04, 06, 09,
H2011
Services, per 15
HW
HM
GT
$0.01
Units
11, 12, 14, 15, 16,
21, 22, 23, 32, 51,
MH
Prepaid
minute unit
Allowed
53, 56, *57, 99,13
Crisis Intervention
Multiple
03, 04, 06, 09, 11,
H2011
Services, per 15
HW
HM
$0.01
Units
12, 14, 15, 16, 21,
22 23, 32, 51, 53,
MH
Prepaid
minute unit
Allowed
56, *57, 99,13
Crisis Intervention
Multiple
02,03, 04, 06, 09,
11, 12, 14, 15, 16,
H2011
Services, per 15
HW
HN
GT
$0.01
Units
21, 22, 23, 32, 51,
MH
Prepaid
minute unit
Allowed
53, 56, *57, 99,13
Crisis Intervention
Multiple
03, 04, 06, 09, 11,
H2011
Services, per 15
HW
HN
$0.01
Units
12, 14, 15, 16, 21,
22, 23, 32, 51, 53,
MH
Prepaid
minute unit
Allowed
56, *57, 99,13
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(AG - VO STD FACILITY) Page 5 of 68
Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per Unit
Allowed
Place of Service
Allowed
Payment
Code
A-1 NWRF
1
2
3
4
Billing Unit
POS
Dx
Type
Crisis Intervention
Multiple
02,03, 04, 06, 09,
11, 12, 14, 15, 16,
H2011
Services, per 15
HW
TD
GT
$0.01
Units
21, 22, 23, 32, 51,
MH
Prepaid
minute unit
Allowed
53, 56, *57, 99,13
Crisis Intervention
Multiple
03, 04, 06, 09, 11,
12, 14, 15, 16, 21,
H2011
Services, per 15
HW
TD
$0.01
Units
22 23, 32, 51, 53,
MH
Prepaid
minute unit
Allowed
56, *57, 99,13
Crisis Intervention
Multiple
02,03, 04, 06, 09,
11, 12, 14, 15, 16,
H2011
Services, per 15
HW
TE
GT
$0.01
Units
21, 22, 23, 32, 51,
MH
Prepaid
minute unit
Allowed
53, 56, *57, 99,13
Crisis Intervention
Multiple
03, 04, 06, 09, 11,
12, 14, 15, 16, 21,
H2011
Services, per 15
HW
TE
$0.01
Units
22, 23, 32, 51, 53,
MH
Prepaid
minute unit
Allowed
56, *57, 99,13
Crisis Intervention
Multiple
03, 04, 06, 09, 11,
12, 14, 15, 16, 21,
H2011
Services, per 15
HW
$0.01
Units
22, 23, 32, 51, 53,
MH
Prepaid
minute unit
Allowed
56, *57, 99, 13
Multiple
03, 04, 06, 09, 11,
T1016
Case Management,
ET
HK
$0.01
Units
12, 14, 15, 16, 21,
MH, SU
Prepaid
per 15 minute unit
Allowed
22, 23, 32, 51, 53,
56, *57, 99,13
Multiple
02, 03, 04, 06, 09,
T1016
Case Management,
ET
HM
GT
$0.01
Units
11, 12, 14, 15, 16,
MH, SU
Prepaid
per 15 minute
Allowed
21, 22, 23, 32, 51,
53, 56, *57, 99,13
Multiple
03, 04, 06, 09, 11,
T1016
Case Management,
ET
HM
HK
$0.01
Units
12, 14, 15, 16, 21,
MH, SU
Prepaid
per 15 minute unit
Allowed
22, 23, 32, 51, 53,
56, *57, 99,13
Multiple
03, 04, 06, 09, 11,
T1016
Case Management,
ET
HM
$0.01
Units
12, 14, 15, 16, 21,
MH, SU
Prepaid
per 15 minute unit
Allowed
22, 23, 32, 51, 53,
56, *57, 99,13
Multiple
02, 03, 04, 06, 09,
T1016
Case Management,
ET
HN
GT
$0.01
Units
11, 12, 14, 15, 16,
MH, SU
Prepaid
per 15 minute unit
Allowed
21, 22, 23, 32, 51,
53, 56, *57, 99,13
Multiple
03, 04, 06, 09, 11,
T1016
Case Management,
ET
HN
HK
$0.01
Units
12, 14, 15, 16, 21,
MH, SU
Prepaid
per 15 minute unit
Allowed
22 23, 32, 51, 53,
56, *57, 99,13
Sign Lang/Oral
Billed
Multiple
03, 09,11,12,
13,15, 19, 22, 32
T1013
Interpreter Srvcs, per
Charges
,
33, 34, 53, *57, 62
MH, SU
Prepaid
15 minutes
Allowed
,
71,72
Sign Lang/Oral
Billed
Multiple
03, 09,11, 12,
13,15, 19, 22, 32,
T1013
Interpreter Srvcs, per
GT
Charges
Units
33, 34, 53, *57, 62,
MH, SU
Prepaid
15 minutes
Allowed
71,72
Multiple
03, 04, 06, 09, 11,
T1016
Case Management,
ET
HN
$0.01
Units
12, 14, 15, 16, 21,
MH, SU
Prepaid
per 15 minute unit
Allowed
22 23, 32, 51, 53,
56, *57, 99,13
Multiple
03, 04, 06, 09, 11,
T1016
Case Management,
ET
$0.01
Units
12, 14, 15, 16, 21,
MH, SU
Prepaid
per 15 minute unit
Allowed
22, 23, 32, 51, 53,
56, *57, 99,13
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(AG - VO STD FACILITY) Page 6 of 68
Modifier
Description
52
Reduced services
53
Discontinued procedure
ET
Crisis only
GT
Via interactive audio and video telecommunication
H9
Court-ordered
HD
Pregnant/parenting women's program
HE
Special population evaluation
HH
Integrated mental health/substance abuse program
HK
Services provided involve multiple staff for safety purposes
HM
Less than bachelor degree level or peer
HN
Bachelors degree level
HT
Multi_disciplinary Multi-disciplinaryteam
HW
Funded by state mental health agency
HZ
Funded by criminal justice treatment account
TD
RN
TE
LPNILVN
U5
Individuals Using Intravenous Drugs IUID
U6
Brief Intervention
U9
Rehabilitation Case Management Intake
UB
Request for Services
UD
WA-PACT
Abbreviation key:
• Y = Youth
• A=Adult
• PPW = Pregnant and Post -Partum Women
• PPW wlchild = Pregnant and Post -Partum Women with child(ren)
• PPW w/o child = Pregnant and Post -Partum Women without child(ren)
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Exhibit A -2.A8
NWSA Rate Schedule
This Exhibit contain the service codes and billing rates that are allowed under the NWSA fund code. Following the Rate Schedule
is a table listing modifiers and their descriptions as well as a key to abbreviations used in the Rate Schedule.
Please see Exhibit B-11 Substance Use Disorder Provisions for services without an associated Service Code that can be
submitted via cost reimbursement invoice with prior approval from the Beacon Account Partnership Director for your Regional
Service Area (RSA).
Definitions
1. Payment Type:
a. Fee for Service (FFS): Claims submitted for health care payments, also known as the Fee for Service (FFS)
payment type, must be cleanly submitted within current Washington State Health Care Authority timely filing
requirements in the format outlined in this Rate Schedule.
b. Prepaid: Encounters submitted for health care reporting purposes, also known as the Prepaid payment type,
must be cleanly submitted to Beacon monthly by the 15th in the format outlined in this Rate Schedule. Payment
for services provided will be made according to the Payment Method identified in Exhibit B-2 Maximum
Contract Amounts.
NWSA Rate Schedule.A8
Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per
Allowed
Billing
Place of Service
Allowed
Payment
Code
A-2 NWSA
1
2
3
4
Unit
Unit
(POS)
Dx
Type
Presumptive Drug
80306
ss
Screening/Direct
HD
U5
$38.40
1 Unit Per
09, 11, 12, 41, 53, *57,
SU
FFS
Optical Observation
Encounter
99
e..Di stick Method
Presumptive Drug
80306
ss
Screening/Direct
HD
$38.40
1 Unit Per
09, 11, 12, 41, 53, *57,
SU
FFS
Encounter
99
Optical Observation
e..Di stick Method
Presumptive Drug
80306
Class
Screening/Direct
U5
$38.40
1 Unit Per
09, 11, 12, 53, *57,
SU
FFS
Optical Observation
Encounter
999
e..Di stick Method
Presumptive Drug
80306
ss
Screening/Direct
$38.40
1 Unit Per
09, 11, 12, 53, *57,
SU
FFS
Optical Observation
Encounter
999
e..Di stick Method
Presumptive Drug
80307
Class Screening/ via
HD
U5
$24.00
1 Unit Per
09, 11, 12, 41, 53, *57,
SU
FFS
Instrumented
Encounter
99
Chemistry Analyzer
Presumptive Drug
80307
Class Screening/ via
HD
$24.00
1 Unit Per
09, 11, 12, 41, 53, *57,
SU
FFS
Instrumented
Encounter
99
Chemistry Analyzer
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Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per
Allowed
Place of Service
Allowed
Payment
Code
A-2 NWSA
1
2
3
4
Unit
Billing
(POS)
Dx
Type
Unit
Presumptive Drug
80307
Class Screening/ via
U5
$24.00
1 Unit Per
09, 11, 12, 41, 53, *57,
SU
FFS
Instrumented
Encounter
99
Chemistry Analyzer
Presumptive Drug
80307
Class Screening/ via
$24.00
1 Unit Per
09, 11, 12, 41, 53, *57,
SU
FFS
Instrumented
Encounter
99
Chemistry Analyzer
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HZ
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
GT
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HD
GT
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HD
U5
GT
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57,62,71,72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HZ
U5
GT
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57,62,71,72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HD
U5
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57,62,71,72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HZ
U5
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HD
U6
GT
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HZ
U6
GT
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57,62,71,72
minutes
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Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per
Allowed
Billing
Place of Service
Allowed
Payment
Code
A-2 NWSA
1
2
3
4
Unit
Unit
(POS)
Dx
Type
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HD
U6
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57,62,71,72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HZ
U6
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HZ
GT
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
U5
GT
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57,62,71,72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
U6
GT
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HD
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
U5
U6
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57,62,71,72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
U5
U6
GT
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HD
U5
U6
GT
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57,62,71,72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HZ
U5
U6
GT
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HD
U5
U6
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
HZ
U5
U6
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57,62,71,72
minutes
BHO-F-COM-MA-MCDI11/2015 Amend 8 - PI D 301052
(AG - VO STD FACILITY) Page 10 of 68
Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per
Allowed
Billing
Place of Service
Allowed
Payment
Code
A-2 NWSA
1
2
3
4
Unit
Unit
(POS)
Dx
Type
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
U5
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
03, 09, 11, 12, 13, 15,
96164
or more patients),
U6
$25.90
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
face-to-face; initial 30
*57, 62, 71, 72
minutes
Health behavior
intervention, group (2
96165
or more patients),
(add
face-to-face; each
$12.95
Unit
Same as primary
SU
FFS
codee))
additional 15 minutes
service
(list separately in
addition to code for
primary service
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HZ
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HD
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HD
U6
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HZ
U6
ST
S53 16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HD
U6
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HZ
U6
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
BHO-F-COM-MA-MCD/11/2015 Amend 8 - PID 301052
(AG - VO STD FACILITY) Page 11 of 68
Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per
Allowed
Billing
Place of Service
Allowed
Payment
Code
A-2 NWSA
1
2
3
4
Unit
Unit
(POS)
Dx
Type
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HD
U5
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HZ
U5
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HD
U5
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HZ
U5
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HD
U5
U6
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HZ
U5
U6
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HD
U5
U6
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HZ
U5
U6
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HD
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
HZ
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
U5
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
U6
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
BHO-F-COM-MA-MCDI11/2015 Amend 8 - PID 301052
(AG - VO STD FACILITY) Page 12 of 68
Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per
Allowed
Billing
Place of Service
Allowed
Payment
Code
A-2 NWSA
1
2
3
4
Unit
Unit
(POS)
Dx
Type
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
U5
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
U5
U6
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
U5
U6
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96167
(with the patient
U6
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
(with the patient
96168
present), face-to-face;
Same as primary
(add-on
each additional 15
$26.58
Unit
SU
FFS
code)
minutes (List
service
separately in addition
to code for primary
service
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HZ
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HD
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HD
U6
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HZ
U6
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HD
U6
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
BHO-F-COM-MA-MCD/11/2015 Amend 8 - PID 301052
(AG - VO STD FACILITY) Page 13 of 68
Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per
Allowed
Billing
Place of Service
Allowed
Payment
Code
A-2 NWSA
1
2
3
4
Unit
Unit
(POS)
Dx
Type
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HZ
U6
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HD
U5
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HZ
U5
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HD
U5
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HZ
U5
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HD
U5
U6
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HZ
U5
U6
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HD
U5
U6
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HZ
U5
U6
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HD
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57,62,71,72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
HZ
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
U5
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
BHO-F-COM-MA-MCDI11/2015 Amend 8 - PID 301052
(AG - VO STD FACILITY) Page 14 of 68
Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per
Allowed
Billing
Place of Service
Allowed
Payment
Code
A-2 NWSA
1
2
3
4
Unit
Unit
(POS)
Dx
Type
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
U6
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
U5
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
'57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
U5
U6
GT
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
*57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
U5
U6
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
'57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
03, 09, 11, 12, 13, 15,
96170
(without the patient
U6
$53.16
Unit
19, 22, 32, 33, 34, 53,
SU
FFS
present), face-to-face;
'57, 62, 71, 72
initial 30 minutes
Health behavior
intervention, family
(without the patient
96171
present), face-to-face;
Same as primary
(add on
each additional 15
$26.58
Unit
SU
FFS
code)
minutes (List
service
separately in addition
to code for primary
service
Alcohol and/or Drug
Multiple
03, 09, 11, 12, 13, 15,
H0001
assessment, per
52
$1.32
Units
19, 22, 53, 57, 71, 72
SU
FFS
minute units
Allowed
Alcohol and/or Drug
Multiple
03, 09, 11, 12, 13, 15,
H0001
assessment, per
53
$1.32
Units
19,22,53,57
9,22,53,57, 71.72
SU
FFS
minute units
Allowed
,
Alcohol and/or Drug
Multiple
03, 09, 11, 12, 13, 15,
H0001
assessment, per
HD
52
$1.32
Units
19, 22, 53, 57, 71, 72
SU
FFS
minute units
Allowed
Alcohol and/or Drug
Multiple
03, 09, 11, 12, 13, 15,
H0001
assessment, per
HD
53
$1.32
Units
19, 22, 53, 57, 71, 72
SU
FFS
minute units
Allowed
Alcohol and/or Drug
Multiple
03, 09, 11, 12, 13, 15,
H0001
assessment, per
HD
U5
52
$1.32
Units
19, 22, 53, 57, 71, 72
SU
FFS
minute units
Allowed
Alcohol and/or Drug
Multiple
03, 09, 11, 12, 13, 15,
H0001
assessment, per
HD
U5
53
$1.32
Units
19, 22, 53, 57, 71, 72
SU
FFS
minute units
Allowed
Alcohol and/or Drug
Multiple
03, 09, 11, 12, 13, 15,
H0001
assessment, per
HD
U5
$1.32
Units
19, 22, 53, 57, 71, 72
SU
FFS
minute units
Allowed
Alcohol and/or Drug
Multiple
03, 09, 11, 12, 13, 15,
H0001
assessment, per
HD
$1.32
Units
19, 22, 53, 57, 71, 72
SU
FFS
minute units
Allowed
Alcohol and/or Drug
Multiple
03, 09, 11, 12, 13, 15,
H0001
assessment, per
U5
52
$1.32
Units
19, 22, 53, 57, 71, 72
SU
FFS
minute units
Allowed
BHO-F-COM-MA-MCD/11/2015 Amend 8 - PID 301052
(AG - VO STD FACILITY) Page 15 of 68
Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per
Allowed
Billing
Place of Service
Allowed
Payment
Code
A-2 NWSA
1
2
3
4
Unit
Unit
(POS)
Dx
Type
Alcohol and/or Drug
Multiple
03, 09, 11, 12, 13, 15,
H0001
assessment, per
U5
53
$1.32
Units
19, 22, 53, 57, 71, 72
SU
FFS
minute units
Allowed
Alcohol and/or Drug
Multiple
03, 09, 11, 12, 13, 15,
H0001
assessment, per
U5
$1.32
Units
19, 22, 53, 57, 71, 72
SU
FFS
minute units
Allowed
Alcohol and/or Drug
Multiple
03, 09, 11, 12, 13, 15,
H0001
assessment, per
$1.32
Units
19, 22, 53, 57, 71, 72
SU
FFS
minute units
Allowed
1H0003
Alcohol and/or drug
$24.00
1 Unit Per
03, 09, 11, 12, 13, 15,
SU
FFS
screeningEncounter
19, 22, 53, 57, 71, 72
Behavioral health
Multiple
02, 03, 09, 11, 12, 13,
H0004
counseling and
HD
GT
$30.50
Units
15, 19, 22, 32, 33, 34,
SU
FFS
therapy, per 15 minute
Allowed
53, *57, 62, 71, 72
unit
Behavioral health
Multiple
02, 03, 09, 11, 12, 13,
H0004
counseling and
HD
U5
GT
$30.50
Units
15, 19, 22, 32, 33, 34,
SU
FFS
therapy, per 15 minute
Allowed
53, *57, 62, 71, 72
unit
Behavioral health
Multiple
02, 03, 09, 11, 12, 13,
H0004
counseling and
HD
U5
U6
GT
$30.50
Units
15, 19, 22, 32, 33, 34,
SU
FFS
therapy, per 15 minute
Allowed
53, *57, 62, 71, 72
unit
Behavioral health
Multiple
03, 09, 11, 12, 13, 15,
H0004
counseling and
HD
U5
U6
$30.50
Units
19, 22, 32, 33, 34, 53,
SU
FFS
therapy, per 15 minute
Allowed
*57, 62, 71, 72
unit
Behavioral health
Multiple
03, 09, 11, 12, 13, 15,
H0004
counseling and
HD
U5
$30.50
Units
19, 22, 32, 33, 34, 53,
SU
FFS
therapy, per 15 minute
Allowed
*57, 62, 71, 72
unit
Behavioral health
Multiple
03, 09, 11, 12, 13, 15,
H0004
counseling and
HD
$30.50
Units
19, 22, 32, 33, 34, 53,
SU
FFS
therapy, per 15 minute
Allowed
*57, 62, 71, 72
unit
Behavioral health
Multiple
02, 03, 09, 11, 12, 13,
H0004
counseling and
therapy, per 15 minute
U5
GT
$30.50
Units
15, 19, 22, 32, 33, 34,
*57,
SU
FFS
unit
Allowed
53, 62, 71, 72
Behavioral health
Multiple
02, 03, 09, 11, 12, 13,
H0004
counseling and
U5
U6
GT
$30.50
Units
15, 19, 22, 32, 33, 34,
SU
FFS
therapy, per 15 minute
Allowed
53, *57, 62, 71, 72
unit
Behavioral health
Multiple
03, 09, 11, 12, 13, 15,
H0004
counseling and
U5
U6
$30.50
Units
19, 22, 32, 33, 34, 53,
SU
FFS
therapy, per 15 minute
Allowed
*57, 62, 71, 72
unit
Behavioral health
Multiple
03, 09, 11, 12, 13, 15,
H0004
counseling and
therapy, per 15 minute
U5
$30.50
Units
19, 22, 32, 33, 34, 53,
*57,
SU
FFS
unit
Allowed
62, 71, 72
Behavioral health
Multiple
03, 09, 11, 12, 13, 15,
H0004
counseling and
therapy, per 15 minute
$30.50
Units
19, 22, 32, 33, 34, 53,
*57,
SU
FFS
unit
Allowed
62, 71, 72
Alcohol and/or drug
1 Unit Per
02, 03, 09, 11, 12, 13,
H0023
outreach
HW
GT
$96.61
Encounter
15. 19, 22, 32, 33, 34,
SU
FFS
53, *57, 62, 71, 72
Alcohol and/or drug
1 Unit Per
02, 03, 09, 11, 12, 13,
H0023
outreach
HW
HD
GT
$96.61
Encounter
15. 19, 22, 32, 33, 34,
SU
FFS
53, *57, 62, 71, 72
BHO-F-COM-MA-MCD/11/2015 Amend 8 - PID 301052
(AG - VO STD FACILITY) Page 16 of 68
Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per
Allowed
Place of Service
Allowed
Payment
Code
A-2 NWSA
1
2
3
4
Unit
Billing
(POS)
Dx
Type
Unit
Alcohol and/or drug
1 Unit Per
02, 03, 09, 11, 12, 13,
H0023
outreach
HW
HD
U5
GT
$96.61
Encounter
15. 19, 22, 32, 33, 34,
SU
FFS
53, 57, 62, 71, 72
Alcohol and/or drug
1 Unit Per
03, 09, 11, 12, 13, 15.
H0023
outreach
HW
HD
U5
$96.61
Encounter
19, 22, 32, 33, 34, 53,
SU
FFS
57, 62, 71, 72
Alcohol and/or drug
1 Unit Per
03, 09, 11, 12, 13, 15.
H0023
outreach
HW
HD
$96.61
Encounter
19, 22, 32, 33, 34, 53,
SU
FFS
57, 62, 71, 72
Alcohol and/or drug
1 Unit Per
02, 03, 09, 11, 12, 13,
H0023
outreach
HW
U5
GT
$96.61
Encounter
15. 19, 22, 32, 33, 34,
SU
FFS
53, 57, 62, 71, 72
Alcohol and/or drug
1 Unit Per
03, 09, 11, 12, 13, 15.
H0023
outreach
HW
U5
$96.61
Encounter
19, 22, 32, 33, 34, 53,
SU
FFS
57, 62, 71, 72
Behavior Health
1 Unit Per
02, 03, 11, 12, 13, 15,
H0025
Prevention Education
GT
$75.00
Encounter
19, 22, 32, 33, 34, 53,
SU
FFS
57, 62, 71, 72
Behavior Health
1 Unit Per
02, 03, 11, 12, 13, 15,
H0025
Prevention Education
HD
GT
$75.00
Encounter
19, 22, 32, 33, 34, 53,
SU
FFS
*57,62,71,72
Behavior Health
1 Unit Per
02, 03, 11, 12, 13, 15,
H0025
Prevention Education
HD
$75.00
Encounter
19, 22, 32, 33, 34, 53,
SU
FFS
57, 62, 71, 72
Behavior Health
1 Unit Per
02, 03, 11, 12, 13, 15,
H0025
Prevention Education
U5
GT
$75.00
Encounter
19, 22, 32, 33, 34, 53,
SU
FFS
57, 62, 71, 72
Behavior Health
1 Unit Per
02, 03, 11, 12, 13, 15,
H0025
Prevention Education
U5
$75.00
Encounter
19, 22, 32, 33, 34, 53,
SU
FFS
57, 62, 71, 72
Behavior Health
1 Unit Per
02, 03, 11, 12, 13, 15,
H0025
Prevention Education
$75.00
Encounter
19, 22, 32, 33, 34, 53,
SU
FFS
57, 62, 71, 72
H0026
Alcohol and/or drug
GT
$150.00
1 Unit Per
57
SU
FFS
prevention
Encounter
H0026
Alcohol and/or drug
HD
GT
$150.00
1 Unit Per
57
SU
FFS
prevention
Encounter
H0026
Alcohol and/or drug
HD
U5
GT
$150.00
1 Unit Per
57
SU
FFS
prevention
Encounter
H0026
Alcohol and/or drug
HD
U5
$150.00
1 Unit Per
57
SU
FFS
prevention
Encounter
H0026
Alcohol and/or drug
HD
$150.00
1 Unit Per
57
SU
FFS
prevention
Encounter
H0026
Alcohol and/or drug
U5
GT
$150.00
1 Unit Per
57
SU
FFS
prevention
Encounter
H0026
Alcohol and/or drug
U5
$150.00
1 Unit Per
57
SU
FFS
prevention
Encounter
H0026
Alcohol and/or drug
$150.00
1 Unit Per
57
SU
FFS
prevention
Encounter
Mental Health
03, 04, 06, 09, 11, 12,
H0046
Services not otherwise
S
specified -1 unit
UB
$22.25
1 Unit Per
14, 15, 16, 21, 22, 23,
*57,
SU
FFS
Encounter
32, 51, 53, 56,
=<15mins; 1 per
99,13
encounter
Sign Lang/Oral
Billed
Multiple
03, 09,11, 12, 13,15,
T1013
Interpreter Srvcs, per
Charges
Units
19, 22, 32, 33, 34, 53,
*57,62,71,72
SU
Prepaid
15 minutes
Allowed
Sign Lang/Oral
Billed
Multiple
03, 09, 11, 12,13,15,
T1013
Interpreter Srvcs, per
GT
Charges
Units
19, 22, 32, 33, 34, 53,
SU
Prepaid
15 minutes
Allowed
*57,62,71,72
BHO-F-COM-MA-MCD/11/2015 Amend 8 - PID 301052
(AG - VO STD FACILITY) Page 17 of 68
Service
Service Description
Modifier
Modifier
Modifier
Modifier
Rate per
Allowed
Billing
Place of Service
Allowed
Payment
Code
A-2 NWSA
1
2
3
4
Unit
Unit
(POS)
Dx
Type
HN
Bachelors degree level
HT
Multi -disciplinary team
HW
Funded by state mental health agency
HZ
Multiple
02, 03, 09, 11, 12, 13,
RN
TE
T1016
Case Management,
GT
U6
Brief Intervention
U9
$13.97
Units
15, 19, 22, 53, 57, 71,
SU
FFS
per 15 minute unit
Allowed
72
Multiple
02, 03, 09, 11, 12, 13,
T1016
Case Management,
HD
GT
$13.97
Units
15, 19, 22, 53, 57, 71,
SU
FFS
per 15 minute unit
Allowed
72
Multiple
02, 03, 09, 11, 12, 13,
T1016
Case Management,
HD
GT
$13.97
Units
15, 19, 22, 53, 57, 71,
SU
FFS
per 15 minute unit
Allowed
72
Multiple
02, 03, 09, 11, 12, 13,
T1016
Case Management,
HD
U5
GT
$13.97
Units
15, 19, 22, 53, 57, 71,
SU
FFS
per 15 minute unit
Allowed
72
T1016
Case Management,
HD
$13.97
Multiple
Units
03, 09, 11, 12, 13, 15,
SU
FFS
per 15 minute unit
Allowed
19 22, 53, 57, 71, 72
T1016
Case Management,
HD
$13.97
Multiple
Units
03, 09, 11, 12, 13, 15,
SU
FFS
per 15 minute unit
Allowed
19 22, 53, 57, 71, 72
Case Management,
Multiple
02, 03, 09, 11, 12, 13,
T1016
U5
GT
$13.97
Units
15, 19, 22, 53, 57, 71,
SU
FFS
per 15 minute
Allowed
72
Case Management,
Multiple
02, 03, 09, 11, 12, 13,
T1016
U5
GT
$13.97
Units
15, 19, 22, 53, 57, 71,
SU
FFS
per 15 minute unit
Allowed
72
T1016
Case Management,
U5
$13.97
Multiple
Units
03, 09, 11, 12, 13, 15,
SU
FFS
per 15 minute unit
Allowed
19, 22, 53, 57, 71, 72
T1016
Case Management,
U5
$13.97
Multiple
Units
03, 09, 11, 12, 13, 15,
SU
FFS
per 15 minute unit
Allowed
19, 22, 53, 57, 71, 72
T1016
Case Management,
$13.97
Multiple
Units
03, 09, 11, 12, 13, 15,
SU
FFS
per 15 minute unit
Allowed
19, 22, 53, 57, 71, 72
Modifier
Description
52
Reduced services
53
Discontinued procedure
ET
Crisis only
GT
Via interactive audio and video telecommunication
H9
Court-ordered
HD
Pregnant/parenting women's program
HE
Special population evaluation
HH
Integrated mental health/substance abuse program
HK
Services provided involve multiple staff for safety purposes
HM
Less than bachelor degree level or peer
HN
Bachelors degree level
HT
Multi -disciplinary team
HW
Funded by state mental health agency
HZ
Funded by criminal justice treatment account
TD
RN
TE
LPN/LVN
U5
Individuals Using Intravenous Drugs IUID
U6
Brief Intervention
U9
Rehabilitation Case Management Intake
UB
Request for Services
UD
WA -PACT
Abbreviation key:
• Y = Youth
• A = Adult
• PPW = Pregnant and Post -Partum Women
BHO-F-COM-MA-MCD/1 1/2015
(AG - VO STD FACILITY)
Amend 8 - PID 301052
Page 18 of 68
• PPW w/child = Pregnant and Post -Partum Women with child(ren)
• PPW w/o child = Pregnant and Post -Partum Women without child(ren)
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Exhibit 13-2.A8
Maximum Contract Amounts
Beacon shall have no obligation to pay for costs or claims in excess of the amounts listed below for the identified periods, unless
this Exhibit is amended pursuant to the terms of the Agreement.
I: General Provisions.
(1) Whenever in this Exhibit B-2 the term "Facility" is used to describe an obligation or duty, such obligation or duty will also
be the responsibility of each individual licensed health care practitioner, Facility, and provider employed or owned by or
under contract with Facility, as the context may require.
(2) Facility agrees:
a. All contracted crisis providers under this Exhibit are delegated crisis providers underthe following Managed Care
Organization (MCO) networks: CCCWA, CHPW AH, AGPWA, Molina's Medicaid network and United's
Washington Medicaid Network
Ik Definitions.
(1) Claims, also known as Fee for Service (FFS) payment type, means an attempt to cause a health care payer to make a
health care payment for a specified health care service.
(2) Encounters, also known as the Prepaid payment type, means the transmission of information equivalent to a health care
claim for a specified health care service for the purpose of health care reporting.
(3) Payment Method:
a. Fee for Service (FFS) means the Facility will submit clean claims within timely filing limits to receive payment for
direct services provided. Claims should be submitted with the rate on the Rate Schedules in this contract.
b. Prepaid:
i. Capacity means the Facility will submit monthly invoices to Beacon for 1/6 of each 6 -month period's
contract maximum and will also submit encounters to document all direct services provided. Direct
Services are those details in the current Rate Schedule(s). Encounters must be submitted monthly by
the 15t.
ii. Cost Reimbursement means the Facility will submit monthly invoices to Beacon for actual costs to be
reimbursed up to the contract maximum and will also submit Encounters to document all direct services
provided. Direct services are those detailed in the current Rate Schedule(s). Encounters must be
submitted monthly by the 15th .
III: Maximum Contract Amounts.
(1) The following table outlines the maximum amounts funded under this contract for the stated period. Unspent funds from
the first 6 -month period may be spent in the second 6 -month period. Unspent funds do not carry over after June 30, 2021.
(2) Monitoring Facility spending against the funds allocated in this Amendment is the responsibility of Facility. Beacon
supports this responsibility by providing Facility with periodic Finance Memos that include payments made by Beacon to
Facility and any remaining funds available for that fiscal year.
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(AG — VO STD FACILITY) Page 20 of 68
Table 1.A8
Maximum Contract Amounts
July 1, 2020 — June 30, 2021
Program or Service
Exhibit
Payment
Funding
Fund
July 2020 —
Jan 2021—
Total
Method
Source
Code
Dec 2020
June 2021*
FY20/21
Non -
Mobile Crisis and
Medicaid
$146,742
$146,742
$293,485
Designated Crisis
B-4
Capacity
State
NWRF
Responder Services
Medicaid
$265,639
$265,639
$531,279
Mobile Outreach
Cost
MHBG
NWMH
$54,868
$54,868
$109,736
Team
B-10
Reimbursement
$29,500
$29,500
$59,000
SABG
NWSA
Substance Use
Fee For
Disorder Services
B-1 1
Service
$15,500
$15,500
$31,000
Certified Mental
Health Professional
Addendum
Cost
Dedicated
with Chemical
to B-11
Reimbursement
Marijuana
N/A
$10,000
$10,000
$20,000
Dependency
Acct (DMA)
Certification
Grand Total
$1,044,499
* Contingent upon Beacon's receipt of signed HCA Amendment confirming funding for this period.
BHO-F-COM-MA-MCD/11/2015 Amend 8 — PID 301052
(AG — VO STD FACILITY) Page 21 of 68
Exhibit B -4.A8
Crisis Program Provisions (Mobile Crisis and Designated Crisis Responder)
This Exhibit contains additional provisions applicable to Covered Services rendered to Eligible Individuals (as defined below)
covered under Crisis Program Provisions (as defined below) offered and/or administered by Washington State Health Care
Authority (HCA). In the event of any conflict between the provisions of the Agreement (including Exhibit 63), and this Exhibit B-4
and subject to the provisions set out in Exhibit B4, the provisions of this Exhibit control as related to services rendered to individuals
receiving Crisis Program Services.
I: General Provisions.
(1) Whenever in this Exhibit B-4 the term "Facility" is used to describe an obligation or duty, such obligation or duty will also
be the responsibility of each individual licensed health care practitioner, Facility, and provider employed or owned by or
under contract with Facility, as the context may require.
(2) Facility agrees:
a. The Facility shall inform, post, and guarantee that each Individual has the following rights in compliance with
WAC 246-341-0600:
i. To information regarding the Individual's behavioral health status.
ii. To receive all information regarding behavioral health treatment options including any altemative or
self-administered treatment, in a culturally -competent manner.
iii. To receive information about the risks, benefits, and consequences of behavioral health treatment
(including the option of no treatment).
iv. To participate in decisions regarding his or her behavioral health care, including the right to refuse
treatment and to express preferences about future treatment decisions.
v. To be treated with respect and with due consideration for his or her dignity and privacy.
vi. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience,
or retaliation.
vii. To request and receive a copy of his or her medical records, and to request that they be amended or
corrected, as specified in 45 C.F.R. Part 164.
viii. To be free to exercise his or her rights and to ensure that to do so does not adversely affect the way
the Facility treats the Individual.
b. The Facility shall ensure Individual self-determination by:
i. Obtaining informed consent prior to treatment from Individuals, or persons authorized to consent on
behalf of an Individual, as described in RCW 7.70.065;
ii. Complying with the provisions of the Natural Death Act (Chapter 70.122 RCW) and state rules
concerning Advance Directives (WAC 182-501-0125); and,
iii. When appropriate, informing Individuals of their right to make anatomical gifts (Chapter 68.64 RCW).
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(AG - VO STD FACILITY) Page 22 of 68
c. Facility shall provide crisis intervention services in accordance with 246-341-0900 (Crisis MH Services —
General), 246-341-0905 (Crisis MH Services—Telephone Support Services), 246-341-0910 (Crisis MH Services
— Outreach Services — Outreach), 246-341-0915 (Crisis MH Services — Stabilization Services), 246-341-0920
(Crisis MH Services — Peer Support), 246.341-0810 (Crisis MH Services — Emergency Involuntary Detention
Services), and 246-341-0748 (OP Services — SUD Info Assistance- Info and Crisis Services), and Chapters
71.05 RCW and 71.34 RCW and be licensed by the DOH under WAC 246-341-0900 to -0915; as well as the
Beacon Level of Care Guidelines which are incorporated herein by reference.
d. Facilities shall provide mobile crisis outreach services in accordance with Chapter 246-341 hereafter referred to
as Mobile Crisis Intervention services consistent with Mobile Crisis Intervention technical specifications as well
as the Beacon Level of Care Guidelines which are incorporated herein by reference.
e. If applicable, Facility shall provide Involuntary Treatment Act Services (ITA) in a manner that includes all services
and administrative functions required for the evaluation for involuntary detenfion or involuntary treatment of
individuals in accordance with Chapters 71.05 RCW, 71.34 RCW, and 71.24.300 RCW. Crisis Services become
Involuntary Treatment Act Services when a Designated Crisis Responder (DCR) determines an individual must
be evaluated for involuntary treatment. The decision making authority of the DCR must be independent of
Beacon's administration. ITA services continue until the end of the involuntary commitment.
f. Facility shall respond in a full and timely manner to law enforcement inquiries regarding an Individual's eligibility
to possess a firearm under RCW 9.41.040(2)(a)(ii).
g. Facility shall coordinate interventions with other community resources, including regional Managed Care
Organization (MCO) when applicable, to provide an array of stabilization and recovery services and avoid
unnecessary hospitalizations.
h. All contracted crisis providers under this Exhibit are delegated crisis providers under the following Managed Care
Organization (MCO) networks: CCCWA, CHPW AH, AGPWA, Molina's Medicaid network and United's
Washington Medicaid Network.
II: Definitions.
(1) Co -responder: Teams consisting of law enforcement officer(s) and behavioral health professional(s) to engage with
individuals experiencing behavioral health crises that does not rise to the level of need for incarceration.
(2) Crisis Hotline: This is the 24[7 regional crisis line that is available to all individuals in the region and serves as the front
door to the crisis system.
(3) Crisis Program: The program is the provision of those crisis services further described within this Exhibit B-4 which are
reimbursable pursuant to the contract between Beacon and the Washington State Health Care Authority.
(4) Crisis Services (Behavioral Health): Crisis Services (Behavioral Health) means providing evaluation and short term
treatment and other services to individuals with an emergent mental health condition or are intoxicated or incapacitated
due to substance use and when there is an immediate threat to the individual's health or safety.
(5) Cultural Humility: The continuous application in professional practice of self -reflection and self -critique, leaming from
patients, and partnership building, with an awareness ofthe limited ability to understand the patient's woridview, culture(s),
and communities.
(6) Culturally Appropriate Care: Health care services provided with Cultural Humility and an understanding of the patient's
culture and community, and informed by Historical Trauma and the resulting cycle of Adverse Childhood Experiences
(ACEs).
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(AG — VO STD FACILITY) Page 23 of 68
(7) Designated Crisis Responder (DCR): Means a person designated by the County or other authority authorized in rule, to
perform the civil commitment duties described in Chapter 71.05 RCW and 71.34 RCW.
(8) Eligible Individuals: For purposes of this Exhibit B4, medically necessary Crisis Services will be available to all individuals
who present with a need for Crisis Services in the Regional Service Area regardless of insurance status, ability to pay,
county of residence, or level of income.
(9) Involuntary Treatment Act (ITA): Allows for individuals to be committed by court order to a hospital or facility for a limited
period of time. Involuntary civil commitments are meant to provide for the evaluation and treatment of individuals with a
behavioral health disorder and who may be either gravely disabled or pose a danger to themselves or others, and who
refuse or are unable to enter treatment on their own. An initial commitment may last up to seventy-two (72) hours, but, if
necessary, individuals can be committed for additional periods of fourteen (14), ninety (90), and one hundred eighty (180)
calendar days of inpatient involuntary treatment or outpatient involuntary treatment (RCW 71.05.180, 71.05.230 and
71.05.290).
(10) Involuntary Treatment Act Services: Includes all services and administrative functions required for the evaluation for
involuntary detention or involuntary treatment of individuals civilly committed under the ITA in accordance with Chapters
71.05 and 71.34 RCW and RCW 71.24.300.
(11) Less Restrictive Alternative (LRA) Treatment: Means a program of individualized treatment in a less restrictive setting
than inpatient treatment that include the services described in RCW 71.05.585.
(12) Mobile Crisis Intervention (MCI): MCI provides a short-term service that is a mobile, on-site, face-to-face therapeutic
response to an individual experiencing a behavioral health crisis for the purpose of identifying, assessing, treating, and
stabilizing the situation and reducing immediate risk of danger to the individual or others. Hours of operation vary by
region. The service includes: A crisis assessment and engagement in a crisis planning process, up to 7 days of crisis
intervention and stabilization services including: on-site face-to-face therapeutic response, psychiatric consultation and
urgent psychopharmacology intervention, as needed, and referrals and linkages to all medically necessary behavioral
health services and supports, including access to appropriate services along the behavioral health continuum of care.
(13) Mobile Crisis Intervention Program Technical Specifications: This a set of documents that describes in detail contracted
program expectations for adult mobile crisis intervention (AMCI) and youth mobile crisis intervention (YMCI). It is a
supplement to the Washington Provider Service Instruction Manual. It is available on Beacon's Washington website
(14) Withdrawal Management (previously known as detoxification): Care and treatment in a residential or hospital setting of
persons intoxicated or incapacitated by alcohol or other drugs during the period in which the person is recovering from
the transitory effects of intoxication or withdrawal. Acute detoxification provides medical care and physician supervision;
subacute detoxification is non-medical.
III: Accountability & Oversight.
(1) Regardless of any provision to the contrary, Washington State Health Care Authority (herein also referred to as 'Payor')
or their respective designees, oversee and monitor the provision of services to individuals on an on-going basis and remain
accountable and responsible for compliance with the terms and conditions of their respective Contract, regardless of the
provisions of the Agreement or any delegation of administrative activities or functions to Beacon.
IV. Comoliance.
(1) Comply with all applicable state and federal laws, rules, and regulations related to services rendered to Eligible individuals,
and applicable requirements of the Beacon and Washington State Health Care Authority Contract.
(2) Comply with Beacon's Program Integrity requirements and HCA approved Program Integrity policies and procedures.
BHO-F-COM-MA-MCD/11/2015 Amend 8 — PID 301052
(AG — VO STD FACILITY) Page 24 of 68
(3) Implement procedures to screen employees, contractors, subcontractors, volunteers, and Board of Directors to ensure
individuals are not excluded from participation in Federal programs. Screening will be completed upon hire and monthly
thereafter.
a. Facility agrees to immediately disclose to Beacon Health Options any exclusion or other event which makes
them ineligible to perform work related directly or indirectly to Federal health care programs.
b. Facility will submit a completed monthly attestation regarding exclusionary checks to Beacon Health Options no
later than the 1 Oth of each month.
c. Facility Oil make evidence of monthly checks available upon request.
(4) Guard against Fraud, Waste and Abuse by creating a Compliance Plan that includes:
a. Implementing written policies, procedures and standards of conduct, including whistleblower protection
b. Designating a Compliance Officer and Compliance Committee
c. Conducting effective ongoing training and education of employees and volunteers
d. Developing effective lines of communication
e. Enforcing standards though well-publicized disciplinary guidelines
f. Conducting internal monitoring and auditing
g. Responding promptly to detected offenses and developing corrective actions;
(5) Participate in Beacon required or HCA sponsored Quality Improvement activities.
(6) Provide Beacon and/or Payors with timely access to records, information and data necessary for Beacon and/or Payors
to meet their respective obligations under their Contract;
(7) Submit all reports and clinical information required by Beacon and/or Payors that may be required by Contract(s) and to
ensure the quality, appropriateness and timeliness of contracted services;
(B) Notify Beacon when a Washington State entity performs any audit related to the activities contained in this contract, and
submit any report and corrective action plan related to the audit to Beacon.
V. Services. Facility agrees to:
(1) Ensure that all services and activities provided under this Contract shall be designed and delivered in a manner
sensitive to the needs of the diverse population.
(2) Initiate actions to develop or improve access, retention, and cultural relevance of treatment, relapse prevention or
other appropriate services, for ethnic minorities and other diverse populations in need of services under this Contract
as identified in their needs assessment.
(3) Participate in training when requested by the HCA. Exceptions must be in writing and include a plan for how the
required information shall be provided to staff.
(4) Facility will use Beacon's Provider Connects portal to register Eligible Individuals for services, including but not
limited to appropriate start date and fund assignment, to ensure they are assigned a unique ID.
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a. Funding registration ends after one year. Individuals continuing to receive services must be re -registered.
(5) Provide interpreter services free of change for Individuals with a preferred language other than English. This includes
the provision of interpreters for Individuals who are Deaf, DeafBlind, or Hard of Hearing. This includes oral interpretation
Sign Language (SL), and the use of Auxiliary Aids and Services as defined in (42 C.F.R. § 438.10(d)(4)).
(6) Interpreter services for Individuals in crisis over -the -telephone.
a. Facility will submit encounter codes for interpretation provided over -the -phone to Individuals in crisis.
b. Reimbursable Services must meet the following criteria:
i. The Individuals must be Medicaid eligible on the date the service took place;
ii. The Individual received a Medicaid covered service by a servicing provider that has a Core Provider
Agreement with HCA;
iii. The Interpretation requests must be for urgent same day events, necessary to assist Individuals
determined to be in crisis;
iv. Services must be provided by a qualified interpreter as described by Section 1557 of the Affordable
Care Act; and
v. The encounter must be submitted to Beacon within forty-five (45) calendar days of the date of service.
c. Do not submit encounter codes for administrative activities including but not limited to: scheduling or reminder
calls, scheduled events, and appointments scheduled more than 24 -hours in advance.
(7) Facility shall use the Integrated Co-Occumng Disorder Screening Tool (GAIN -SS found at hftl)s://www.hca.wa.gov/billers-
providers-partners/behavioral-health-recovery/gain-ss) and shall train staff that will be using the tool(s) to address the
screening and assessment process, the tool, and quadrant placement. Failure to implement and maintain the process
may result in corrective action.
(8) Deliver crisis response and intervention services, referral and linkage services to all individuals located in the designated
Regional Service Area/County in accordance with CFR 42, WAC 246-341, current DCR protocols set out by the Division
of Behavioral Health and Recovery (DBHR) (or its successor), and any other documents incorporated by reference.
(9) The Facility will implement the requirements of 2007-2008 Substitute House Bill 1456, including the provision of secondary
personnel when deemed necessary by acting Crisis Supervisor, provision by Facility of a wireless telephone or
comparable device for the purpose of emergency communication, and annual training on safety and violence prevention
topics described in RCW 49.19.030 for all who work directly with clients. This act is known as the Marty Smith law.
(10) Crisis Services shall be delivered as follows:
a. Stabilize Individuals as quickly as possible and assist them in returning to a level of functioning that no longer
qualifies them for Crisis Services. Stabilization Services will be provided in accordance with WAC 246-341-0915.
b. Provide solution -focused, person -centered, and Recovery -oriented interventions designed to avoid unnecessary
hospitalization, incarceration, institutionalization, or out of home placement.
c. Coordinate closely with regional MCOs, community court system, First Responders, criminal justice system,
inpatient/residential service providers, Tribal governments, ICHPs, and outpatient behavioral health providers to
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operate a seamless crisis system and acute care system that is connected to the full continuum of health services
and inclusive of processes to improve access to timely and appropriate treatment for Individuals with current and
or prior criminal justice involvement.
d. Engage the Individual in the development and implementation of crisis prevention plans to reduce unnecessary
crisis system utilization and maintain the Individual's stability.
e. Develop and implement strategies to assess and improve the crisis system over time.
(11) Core MCI services the Facility shall provide include:
a. Coordination with co -responders within the region.
b. A comprehensive crisis assessment, including a mental status exam, crisis precipitants, behavioral health and
physical health history, medication history and compliance, safety/risk issues with the individual and / or
caregiver(s) / natural supports, and functioning at home, work, and community.
c. Providing support, information, understanding and consultation to caregiver(s) / natural supports who are likely
experiencing (normal, but often overwhelming) stress, concern, and exhaustion so that they are best equipped
to participate in the intervention, make decisions, and support their loved one.
d. Discussing and activating caregiver/ natural support strengths and resources to identify how such strengths and
resources impact their ability to care for the individual's behavioral health needs.
e. Assessing the individual's behavior and the responses of caregivers)/natural support and others to the
individual's behavior
f. Identifying current providers, including state agency involvement.
g. Attempt to obtain Release of Information (ROIs) and document stakeholder coordination in the clinical record.
h. Ensure that all calls, services, and outcomes are documented in compliance with record content and
documentation requirements in accordance with WAC 246-341-0900 to -0915.
I. Identifying natural supports and community resources that can assist in stabilizing the situation and offerongoing
support to the individual and caregiver(s).
j. Identification and inclusion of professional and natural supports (e.g., therapist, neighbors, relatives) who can
assist in stabilizing the situation and offer ongoing support.
k. Psychiatric consultation and urgent psychopharmacology intervention (if current prescribing provider cannot be
reached immediately or K no current provider exists), as needed, from an on-call psychiatrist or Psychiatric Nurse
Mental Health Clinical Specialist.
I. Confirm whether the Individual has a Crisis Alert on file and get access to any risk management / safety plans,
if available. If the Individual does not already have one, develop risk management / safety plan.
m. Provide crisis intervention, including solution -focused crisis counseling and brief interventions that address
behavior and safety.
n. Referrals and linkages to all medically necessary behavioral health services and supports, including access to
appropriate services along the behavioral health continuum of care.
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o. For individuals who are receiving Program for Assertive Community Treatment (PACT) or similar program, MCI
staff shall coordinate with the individual's care coordinator throughout the delivery of the Mobile Crisis service.
p. The MCI team shall coordinate with the individual's primary care provider, any other care management program,
or other behavioral health providers providing services to the individual throughout the delivery of the Mobile
Crisis service.
q. MCI is not intended for the purposes of accessing respite, out -of -home placement, or outpatient treatment or to
supplant existing front-line responses for adults receiving services from a primary provider (e.g. primary care,
PACT, residential, etc.).
r. MCI teams will respond in the following timeframes:
i. Triage calls within 15 minutes of initial request
ii. Strive to respond in person within 90 minutes or less, but within no more than the state requirement of
2 hours.
(12) Following completion of a Mobile Crisis Intervention, if the MCI clinician determines that DCR intervention may be
medically necessary, the clinician will manage referrals and coordination of care.
a. MCI and DCR programs must coordinate and communicate daily to ensure effective community response
management.
b. MCIs shall be utilized whenever possible to provide the initial response in order to maximize the efficiency of
limited DCR resources by helping to ensure DCRs respond to cases specific to RCW 71.05.
(13) If the Facility provides DCR services, core services include:
a. Deliver Involuntary Treatment Act Services including all services and administrative functions required for the
evaluation for involuntary detention or involuntary treatment of individuals in accordance with WAC 246-341-
0810, Chapter 71.05 RCW, 71.34 RCW and 71.24.300 RCW. The decision-making authority of the DCR shall
be independent of Beacon Health Options, Inc.
i. The Facility will have a process in place to determine if an individual is impaired due to the presence of
substances in his/her system.
ii. The Facility will perform functions necessary for facilitation of voluntary psychiatric inpatient care and
least restrictive alternative care, including all necessary documentation and administrative functions.
iii. The Facility will monitor all individuals placed on Least Restrictive Alternatives (LRAs) and Conditional
Release (CR) in accordance with RCW 71.05.320, RCW 71.05.340, and RCW 71.05.585 respectively.
iv. The Facility shall report to HCA and Beacon when it is determined an Individual meets detention criteria
under RCW 71.05.150, 71.05.153, 71.34.700 or 71.34.710 and there are no beds available at the
Evaluation and Treatment Facility, Secure Withdrawal Management and Stabilization facility,
psychiatric unit, or under a single bed certification, and the DCR was not able to arrange for a less
restrictive alternative for the Individual.
v. When the DCR determines an Individual meets detention criteria, the investigation has been completed
and when no bed is available, the DCR shall submit an Unavailable Detention Facilities report to HCA
and Beacon within 24 hours. The report shall include the following:
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1. The date and time the investigation was completed;
2. A list of facilifies that refused to admit the Individual;
3. Information sufficient to identify the Individual, including name and age or date of birth; and;
4. Other reporting elements deemed necessary or supportive by HCA.
A When a OCR submits a No Bed Report due to the lack of an involuntary treatment bed, a face-to-face
re -assessment is conducted each day by the DCR or Mental Health Professional (MHP) employed by
the crisis provider to verify that the person continues to require involuntary treatment. If a bed is still
not available, the DCR sends a new Unavailable Detention Facilities Report (No Bed Report) to HCA
and Beacon and the DCR or MHP works to develop a safety plan to help the person meet their health
and safety needs. The DCR continues to work to find an involuntary treatment bed.
b. The Facility will respond in person when requested by community stakeholders and providers unless: (1) there
are significant safety issues identified, documented, and reported to Beacon; and / or (2) the requesting
stakeholder or provider agree that a face-to-face response is not required.
c. The Facility will have clinicians available 24/7 who have expertise in behavioral health issues pertaining to adults,
children, and families.
d. The Facility's community response time will be no longer than 2 hours or as mandated by WAC and RCW.
e. The Facility will seek less restrictive alternatives for all individuals served, with effort made to maintain an
individual in his or her community, and voluntary placement when a higher level of care is clinically indicated.
The Facility may provide crisis and community stabilization services, in accordance with WAC 246-341-0915, to
stabilize individuals and assist them in returning to a level of functioning. These services may include brief
counseling, skill building, case management, check -ins by phone or in person and other supportive services
including engagement with family and significant others for support.
f. The Facility will coordinate with the outpatient provider system, including the MCO when appropriate, and
participate in treatment planning and treatment team meetings when requested.
g. The Facility may provide targeted, short term interventions including next day immediate access to outpatient
services and/or follow up care. These services may include the following:
L Face to face therapeutic response
it. Telephonic psychiatric consultation
iii. Solution focused crisis counseling, including teaching of coping and behavior management skills,
mediation, parentffamily support and psychoeducation
iv. Telephonic support to individual and family
v. Collateral contacts
(14) Facility will execute and maintain inter -agency agreements or memorandum of understanding (MOU) documenting the
provision of applicable crisis services (Mobile Crisis Intervention, Designated Crisis Responder) with applicable key
partner organizations including but not limited to school districts, child welfare, law enforcement, emergency services,
hospitals, providers, etc.
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(15) Partner with Beacon to organize and facilitate community forum(s), on an agreed upon frequency, for the purposes of
obtaining feedback about crisis services, identifying service gaps, and ensuring crisis services are responsive to the
unique needs of communities within the region.
(16) Implement a client satisfaction survey for individuals served through crisis services and report data to Beacon and at
agreed upon community forums. Results from the client satisfaction survey will inform quality improvement initiatives and
program development goals.
VI. Reporting Requirements. Reporting requirements include, but are not limited to, the following
(1) Facility must submit complete and accurate reports and data required under this Exhibit, including encounter data that
complies with HCA Service Encounter Reporting Instructions (SERI) Guide, HCA Encounter Data Reporting Guide
(EDRG), and Behavioral Health Supplemental Transactions that complies with the Behavioral Health Data System
(BHDS) Guide.
(2) Facilitymust provideclaims and/or encounter codes to Beacon for reporting tothe Washington State Health CareAuthority
in accordance with the Rate Schedules in this Contract. Claims submitted for health care payments, also known as the
Fee for Service (FFS) payment type, must be submitted within current Washington State Health Care Authority timely
filing requirements or they will be denied for timely filing. Encounters submitted for health care reporting purposes, also
known as the Prepaid paymenttype, must be submitted to Beacon monthly bythe 15th. Claims and encounter submissions
are used to reconcile services provided and directly impact future rate setting and/orfunding available in the RSA. Failure
to submit claims and/or encounters for services rendered as outlined in your rate schedule(s) may result in future budget
reductions.
(3) When reporting encounters, the fund code and, for those with Medicaid, the individual's Provider One ID, must be provided
so proper allocation of cost can be distinguished for the Payor.
(4) Facility must collect and report to Beacon all applicable transactions described in the Department of Social and Health
Services (DSHS) most current Behavioral Health Data System (BHDS) Guide, including but not limited to the following:
a. Demographics 020.08
b. DCR Investigation 160.05
c. ITA Hearing 162.05
d. Mobile Crisis Response 165.01
(5) Unless there is an established SFTP site with Beacon, reports should be submitted to the following email address, which
is monitored multiple times each day: BeaconWAAS00beaconhealthoptions.com.
a. The name of the report should be included in the email subject line.
(6) Facility will submit a completed monthly attestation regarding exclusionary checks to Beacon Health Options no later than
the 10th of each month.
(7) Facility shall enter the Eligible Individual's Beacon assigned identification number in the field titled "Client ID".
(8) Facility shall submit Daily Crisis Logs that provide summary of all crisis interventions, including but not limited to, core
demographics, date of contact, referral reason, intervention provided, outcome, follow up services to be provided, and
recommendations for further clinical care coordination by MCO or Beacon.
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(9) Facility shall administer a client satisfaction survey upon completion of services and provide an annual report with an
analysis of survey results and recommendations to Beacon. At minimum, the analysis shall include: number of surveys
completed, percentage of completed surveys relative to clients served, results of surveys, comparison of results over time,
trends found in population and actions taken or to be taken by crisis provider to improve client satisfaction. Annual report
is due by January 10 for the previous calendar year.
(10) Facility will provide a quarterly report of progress towards execution and/or maintenance of inter -agency
agreements/MOUs including the following information: organizations with executed agreements and maintenance
status, organizations in discussion and status of discussions, organizations not yet approached and plans for
engagement.
(11) Facility shall report dashboard data monthly to Beacon to fulfill reporting requirements to key stakeholders and the HCA,
including but not limited to, the following elements when those services are provided by the Facility:
Crisis Dashboard Reporting Elements.A8
Data
Reported by
Key
IP = In Person
TH = Telehealth
MCI (Adult/Youth)
Responses that do
not require a DCR
DCR
Referral Source
Regional Crisis Line
X
X
MCI
X
Law Enforcement (Sheena's Law)
X
Warm hand off in clinic or brought over to facility
X
Family Member Petition (Joel's Law)
X
Co -responder Team
X
Jail or Juvenile Detention
X
Other (provide details)
Total number referrals received
X
X
Response Time
For Initial Dispatch (average minutes)
X
X
From Request to Face -to -Face Arrival (average minutes)
X
X
encounters in initial 2 -person response
X
Emergent (respond within 2 hours)
X
X
Emergent Performance Incentive (respond within 90 minutes)
X
Urgent (as scheduled within 24 hours), defined as:
X
X
By next judicial day for someone in secure setting
Definitions provided for information only,
subcategory reporting of Urgent response
times not currently required.
No more than 6 hours post medical clearance: ER observation,
refused voluntary treatment
Brought by Peace Officer, up to 12 hours post medical clearance:
crisis stabilization, E&T, hospital ED, triage, secure detox, SLID
Within 3 hours must be assessed; determination within 12 hours of
notice
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Data
Reported by
Key
IP = In Person
TH = Telehealth
MCI (Adult/Youth)
Responses that do
not require a DCR
DCR
Up to 12 hours to evaluate minors (13 + years old) brought to E&T,
hospital ER, secure detox
Location of Intervention
Community
X
X
ER/Hospital
X
Jail or Juvenile Detention
X
Other (provide details)
X
X
Placement
# Unavailable bed reports
X
# Single Bed Certs
X
# Out of County Placements
X
Outcomes
Phone Consult Only: Inappropriate Referral
X
Phone Consult Only: Refused Service/Declined IP Response (individual
or family)
X
Refer to Community Stabilization (TH or IP)
X
Refer to DCR (TH or IP)
X
Resolved (TH or IP): # result in Referral to 7 -day Crisis CM Services
X
Resolved (TH or IP): % seen in 7 day CM follow-up
X
Resolved (TH or IP): Follow-up contact made within 24 hours
X
Resolved (TH or IP): Seen by follow-up PCP/OP in 7 days
X
# Face -to -Face crisis contacts (TH or OP)
X
diverted from Higher Level of Care (HLOC)
X
with unplanned contact/return to crisis system
X
X
Results in Referral to OP Treatment
X
Results in Referral to Voluntary IP Treatment
X
Results in Detention under ITA: MH Detention
X
Results in Detention under ITA: Referral to AOT, LRA, CR
X
Results in Detention under ITA: SLID Detention (Ricky's Law)
X
Referred to Law Enforcement
X
Unable to Contact / Refused Service
X
X
Other or No Further Steps
X
Total number of ITA Investigations
X
Total number unique individuals served
X
X
Court Hearing Outcomes
# 14 -day hearing outcomes
X
# 90 -day hearing outcomes
X
# 180 -day hearing outcomes
X
# LRA/CR in place
X
Individuals monitored during reporting period
X
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Data
Reported by
Key
IP = In Person
TH = Telehealth
MCI (Adult/Youth)
Responses that do
not require a DCR
DCR
Individual unique ID #
X
Type of Service Provided
X
Start and End dates
X
Treatment Provider and Phone #
X
Health insurance coverage
X
# LRA/CR revoked
X
a. Data must be submitted by the 10th day of the following month.
b. Definitions of each element as well as formatting requirements will be provided by Beacon upon request or when
there is a change to an element or formatting.
(12) Failure to meet reporting requirements may result in a Corrective Action Plan (CAP)
VII. Documents Incorporated by Reference.
(1) Each of the documents listed below are incorporated by this reference into this Exhibit B-4 as though fully set forth herein,
including any amendments, modifications or supplements thereto. All services shall be provided in accordance with these
documents and legal authorities:
a. Beacon's contracts, program agreements, exhibits, amendments, and any other agreements with the
Washington State Health Care Authority;
b. The Medicaid State Plan and the 1915(b) Medicaid Waiver;
c. The Health Care Authority policies, the State Medicaid Manual (SMM) as applicable, the BARS Manual and any
applicable BARS Supplemental Instructions;
d. State laws and regulations including the Revised Code of Washington and the Washington Administrative Code;
e. Beacon External Policies and Procedures, including Beacon's Provider Handbook and Washington State ASO
Provider Handbook: Supplemental Appendix;
f. CPT Manual, HCPC Manual, and Washington State Service Encounter Reporting Instructions;
g. The Code of Federal Regulations Title 45 CFR and Title 42 CFR; and,
h. Title XIX of the Social Security Act.
VIII. Term & Termination.
(1) In addition to and notwithstanding the provisions set forth in the Agreement, this Exhibit maybe suspended or terminated
by Beacon immediately upon written notice if:
a. Facility is disqualified, terminated, suspended, debarred, or otherwise excluded from or ineligible for participation
under the program or any other state or federal government-sponsored health program; or
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b. The Agreement is terminated or not renewed.
IX. Confidential Information.
(1) Nothing contained in the Beacon Facility Agreement or associated exhibits shall be construed as prohibiting Facility from
sharing information with the public as required by federal, state or local law.
X. Provider Communication.
(1) Nothing under this Agreement prohibits, or otherwise restricts, a healthcare professional acting within the lawful scope of
practice, from advising or advocating on behalf of an individual who is his or her patient, for the following:
a. The individual's health status, medical care, or treatment options, including any alternative treatment that may
be self-administered.
b. Any information the individual needs in order to decide among all relevant treatment options.
c. The risks, benefits, and consequences of treatment or non -treatment.
d. The individual's right to participate in decisions regarding his or her health care, including the right to refuse
treatment, and to express preferences about future treatment decisions.
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Exhibit B -8.A8
Washington State Health Care Authority Specific Provisions
In addition to the obligations set forth elsewhere in this Agreement, Beacon and Facility agree to comply with the following
requirements with respect to Covered Services rendered to Eligible Individuals subject to Beacon's contract with the Washington
Health Care Authority. Capitalized terms used but not defined in this Exhibit B-8 shall have the meanings set forth in the Agreement.
I: Hold Harmless.
(1) Facility hereby agrees that in no event, including, but not limited to nonpayment by Beacon, or Payor, Beacon's insolvency
or the insolvency of Payor, or breach of this contract will Facility bill, charge, collect a deposit from, seek compensation,
remuneration, or reimbursement from, or have any recourse against an Eligible Individual or person acting on their behalf,
other than Beacon or Payor, for Covered Services provided pursuant to this contract. This provision does not prohibit
collection of deductibles, copayments, coinsurance, and/or payment for non -covered services, which have not otherwise
been paid by a primary or secondary issuer in accordance with regulatory standards for coordination of benefits.
(2) Facility agrees, in the event of Beacon or Payors insolvency, to continue to provide the services promised in this contract
to Eligible Individuals for the duration of the period for which premiums on behalf of the Eligible Individual were paid to
Payor or until the Eligible Individual's discharge from inpatient facilities, whichever time is greater.
(3) Notwithstanding any other provision of this Agreement, nothing in this Agreement shall be construed to modify the rights
and benefits contained in the Member's Plan.
(4) Facility may not bill the Eligible Individual for Covered Services (except for deductibles, copayments, or coinsurance)
where Beacon or Payordenies payments because the provideror Facility has failed to comply with the terms or conditions
of this Agreement.
(5) Facility further agrees (i) that the provisions of (a), (b), (c), and (d) of this subsection shall survive termination of this
Agreement regardless of the cause giving rise to termination and shall be construed to be for the benefit of Eligible
Individuals, and (ii) that this provision supersedes any oral or written contrary agreement now existing or hereafter entered
into between Facility and Eligible Individuals or persons acting on their behalf.
(6) In addition to the requirements of Section 3.5 of the Agreement, when Facility contracts with Practitioners to provide
covered services to Eligible Individuals with the expectation of receiving payment directly or indirectly from Beacon or
Payor such Practitioners must agree to abide by the provisions of (a), (b), (c), (d), and (e) of this subsection.
(7) Facility acknowledges that Facility or its Practitioners that willfully collect or attempt to collect an amount from an Eligible
Individual knowing thatcollection to be in violation ofthisAgreement constitutes a class C felony under RCW 48.80.030(5).
II: Amendments.
(1) Notwithstanding Sections 5.4(b) and 11.2 of the Agreement, Facility must be given reasonable notice of not less than sixty
(60) days of changes that affect Facility or its Practitioners' compensation or that affect healthcare service delivery unless
changes to federal or state law or regulations make such advance notice impossible, in which case notice must be
provided as soon as possible. Notice to Facility is considered notice to its Practitioners under this Agreement.
a. Subject to any termination and continuity of care provisions of the Agreement, Facility may terminate the
Agreement without penalty if Facility does not agree with the changes, subject to the requirements in Article VIII
of the Agreement
b. A material amendment to the Agreement may be rejected by Facility. The rejection will not affect the terms of
the existing Agreement. A material amendment has the same meaning as in RCW 48.39.005.
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(2) No change to the Agreement maybe made retroactive without the express written consent of the Facility.
III: Practitioner Relationships.
(1) Beacon will not in any way preclude or discourage Facility from informing Eligible Individuals of the care they require,
including various treatment options, and whether in their view such care is consistent with medical necessity, medical
appropriateness, or otherwise covered by the individual's Plan. Beacon will not prohibit, discourage, or penalize Facility
or its Practitioners otherwise practicing in compliance with the law from advocating on behalf of an Eligible Individual with
Beacon, a Payor, or a Plan. Nothing in this section shall be construed to authorize Facility to bind Beacon or Payor to pay
for any service.
(2) Beacon will not preclude or discourage Eligible Individuals or those paying for their coverage from discussing the
comparative merits of different Payors or Plans with Facility or its Practitioners. This prohibition specifically includes
prohibiting or limiting Facility participating in those discussions even if critical of Beacon, a Payor or a Plan.
(3) Beacon will not penalize Facility because Facility, in good faith, reports to state or federal authorities any act or practice
by Beacon that jeopardizes an individual's health or welfare or that may violate state or federal law.
IV. Confidentiality of Health Records.
(1) In addition to the other requirements of the Agreement, Facility will make health records available to appropriate state and
federal authorities involved in assessing the quality of care or investigating the grievances or complaints of Eligible
Individuals subject to applicable state and federal laws related to the confidentiality of medical or health records.
(2) Information about Individuals, including their medical records, shall be kept confidential in a manner consistent with state
and federal laws and Regulations.
V. Discrimination Prohibited.
(1) Beacon is responsible for ensuring that Facility and its Practitioners furnish Covered Services to each Eligible
Individuals without regard to the individual's enrollment in a Plan as a private purchaser of a Plan or as a participant
in publicly financed programs of health care services. This requirement does not apply to circumstances when the
Facility should not render services due to limitations arising from lack of training, experience, skill, or licensing
restrictions
VI. Dispute Resolution.
(1) Notwithstanding those provisions in Article X of the Agreement, the parties are not required to engage in binding arbitration;
however, parties agree to otherwise follow the dispute resolution process prior to judicial remedies. Facility has thirty days
after the action giving rise to a dispute to complain and initiate the dispute resolution process. Beacon shall render a
decision on Facility complaints within a reasonable time for the type of dispute. In the case of billing disputes, Beacon
must render a decision within sixty (60) days of the complaint.
VII. Payments. Beacon shall pay Facility as soon as practical but at a minimum:
(1) Beacon shall pay ninety-five percent (95%) of the monthly volume of Clean Claims within thirty (30) days of receipt. For
purposes of this Section VII, Clean Claim means a claim that has no defect or impropriety, including any lack of any
required substantiating documentation, or particular circumstances requiring special treatment that prevents timely
payments from being made on the claim under this section.
(2) Beacon shall pay or deny ninety-five percent (95%) of all claims within sixty days of receipt by Beacon and ninety-nine
percent (99%) of all clams within ninety (90) calendar days of receipt, except as otherwise agreed to in writing by the
parties on a claim -by -claim basis.
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(3) The receipt date of a claim is the date that Beacon receives either written or electronic notice of the claim. Beacon shall
have a reasonable method for responding to inquiries about claims.
(4) In the event that Beacon fails to meet the requirements set forth in this Section 7, Beacon shall pay interest on undenied
and unpaid Clean Claims more than sixty-one (61) days old until such time as Beacon meets requirements of subsections
7 (a) and 7 (b). Interest shall be assessed at the rate of one percent (1%) per month and shall be calculated monthly as
simple interest prorated for any portion of the month. In the event that interest is due and payable to the Facility, Beacon
shall add the interest payable to the amount of the claim in question without the necessity of Provider submitting an
additional claim. Any interests paid under this Section shall not be applied by Beacon to an individual's deductible,
copayment, coinsurance or other individual's cost share obligation.
(5) Denial of a claim by Beacon shall include specific reason that the claim was denied. If the denial was based on medical
necessity, then Beacon shall, upon the request of Facility, disclose the supporting basis for the denial.
(6) Beacon's Provider Dispute Resolution (PDR) Process can be utilized for claims that deny for administrative, non -clinical
reasons as outlined in the WA State ASO Provider Handbook: Supplement.
(7) The provisions of this Section 7 shall not apply to claims for which there is substantial evidence of fraud or
misrepresentation by Facility or to instances in which Beacon has not been granted reasonable access to information
under Facility's control.
(8) Beacon and Facility are not required to comply with the provisions of this Section 7, if the failure to comply is occasioned
by any act of God, bankruptcy, act of a governmental authority responding to an act of God or other emergency, or the
result of a strike, lockout, or other labor dispute.
(9) Beacon shall comply with terms and conditions of payment outlined in WAC 284-170-431.
VIII. Audit/Access to Records.
(1) Facility shall comply with all applicable required audits including authority to conduct a Facility inspection, and the federal
Office of Management and Budget (OMB) Super Circular, 2 C.F.R. 200.501 and 45 C.F.R. 75.501 audits.
(2) Upon request, the Facility shall allow HCA or any authorized state or federal agency or authorized representative, access
to all records pertaining to this Contract, including computerized data stored by the Facility. The Facility shall provide and
furnish the records at no cost to the requesting agency.
(3) On -Site Inspections
a. The Facility must provide any record or data pertaining to this Contract including, but not limited to:
i. Medical records;
ii. Billing records;
iii. Financial records;
iv. Any record related to services rendered, quality, appropriateness, and timeliness of service; and
v. Any record relevant to an administrative, civil or criminal investigation or prosecution.
b. Upon request, the Facility shall assist in such review, including the provision of complete copies of records.
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c. The Facility must provide access to its premises and the records requested to any state or federal agency or
entity, including, but not limited to: HCA, OIG, MFCD, Office of the Comptroller of the Treasury, whether the
visitation is announced or unannounced.
(4) Beacon may not access medical records unrelated to Eligible Individuals served under this contract. Except that this
provision shall not limit Beacon's or Payor's right to ask for and receive information relating to the ability of the Facility to
deliver health care services that meet the accepted standards of medical care prevalent in the community.
(5) Access to medical records for the purpose of audit by Beacon, or the Payors is limited to only that necessary to perform
the audit.
(6) The billing audit rights granted to Beacon and the Payors are reciprocal so that Facility may audit the denial of its claims.
IX. Miscellaneous.
(1) Compliance with law. Beacon and Facility shall comply with all applicable Washington laws governing this Agreement
and the provision of Covered Services to Eligible Individuals. In the event that any applicable Washington law conflicts
with the terms of this Exhibit B-8, such terms shall be deemed amended to the extent necessary for consistency with the
applicable Washington law.
(2) Conflicts or inconsistencies. In the event of any conflict or inconsistency between the terms of this Exhibit B-8 and the
terms in any other section of the Agreement including other Exhibit Bs, then this Exhibit B-8 shall control; provided
however, that if Beacon and Facility are capable of complying with both the requirements of such other section and this
Exhibit B-8, nothing herein shall be construed as waiving the obligations of Beacon or Facility under such other section.
X. Additional Provisions Required of the Washington State Health Care Authority (HCA).
(1) The following provisions are required by (i) federal statutes and regulations applicable to medical assistance programs for
the indigent, (ii) state statutes and regulations applicable to medical assistance programs for the indigent, or (iii) contracts
and agreements between the Health Plan and the state agencies responsible for regulating risk-based medical assistance
programs for the indigent. These provisions shall be automatically modified to conform to subsequent amendments to
such statutes, regulations, and agreements. Further, any purported modifications to these provisions inconsistent with
such statutes, regulations, and agreements shall be null and void.
(2) Facility shall provide reasonable access to facilities and financial and medical records for duly authorized representatives
of the CMS, HCA, Department of Social & Health Services ("DSHS") or the Department of Health & Human Services
("DHHS") for audit purposes and immediate access for Medicaid fraud investigators.
(3) Facility shall investigate and disclose to Beacon and HCA immediately upon becoming aware of any person in their
employment who has been convicted of a criminal offense related to that person's involvement in any program under
Medicare, Medicaid, or Title XX of the Social Security Act since the inception of those programs.
(4) Facility shall require nondiscrimination in employment and Individual services.
(5) Facility shall conduct criminal background checks and maintain related policies and procedures and personnel files
consistent with requirements in Chapter 43.43 RCW and, Chapter 246-341 WAC.
(6) Facility shall completely and accurately report encounter data to Beacon. Facility shall have the capacity to submit all
required data to enable Beacon to meet the requirements in the Encounter Data Transaction Guide published by HCA.
(7) Facility shall comply with Beacon's fraud and abuse policies and procedures.
(8) Facility shall not assign this Agreement without HCA's written agreement.
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(9) Facility shall comply with any term or condition of Beacon's contracts with HCA that is applicable to the services to be
performed by Facility.
(10) Facility shall accept payment from Beacon as payment in full and shall not request payment from HCA or any Eligible
Individual for Covered Services performed under this Agreement.
(11) Facility agrees to hold harmless HCA and its employees, CMS and its employees, and all enrollees served under the
terms of this Agreement in the event of non-payment by Beacon. Facility further agrees to indemnify and hold harmless
HCA and its employees against all injuries, deaths, losses, damages, claims, suits, liabilities, judgments, costs and
expenses which may in any manner accrue against HCA or its employees through the intentional misconduct, negligence,
or omission of Facility, its agents, officers, employees or contractors.
(12) Facility agrees to comply with the HCA appointment wait time standards. Facility agrees to Beacon's regular monitoring
of timely access to Facility's services, and agrees to corrective action up to and including termination for cause in the
event that Facility fails to comply with the appointment wait time standards.
(13) If, at any time, Beacon determines that Facility is deficient in the performance of its obligations under the Agreement,
Beacon may require Facility to develop and submit a corrective action plan that is designed to correct such deficiency.
a. Beacon shall approve, disapprove, or require modifications to the corrective action plan based on its reasonable
judgment as to whether the corrective action plan will correct the deficiency.
Facility shall, upon approval of Beacon, immediately implement the corrective action plan, as approved or
modified by Beacon.
c. Facility's failure to implement any corrective action plan may, in the sole discretion of Beacon, be considered
breach of the Agreement, subject to any and all contractual remedies including termination of the Agreement
with or without notice.
(14) Facility shall make reasonable accommodation for enrollees with disabilities, in accord with the Americans with Disabilities
Act, for all Covered Services and shall assure physical and communication barriers shall not inhibit enrollees with
disabilities from obtaining Covered Services.
(15) Facility shall comply with all Program Integrity provisions as documented in Beacon's Provider Manual and asset forth by
42 CFR 438.608 and Beacon's contracts with HCA.
(16) Facility shall ensure that all persons applying for services under this Agreement are screened for financial eligibility.
Specifically, Facility shall:
a. Capture sufficient demographic, financial, and other information to support eligibility decisions and reporting
requirements.
b. Check Medicaid eligibility, including conducing a benefit inquiry in the ProviderOne system, prior to each service
delivery.
c. Conduct an inquiry regarding each Eligible Individual' s continued financial eligibility no less than once each
month.
d. Document the evidence of each financial screening in the individual's records.
e. Update funding information when the funding source changes.
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f. To be eligible for any non -crisis behavioral health service under this Agreement, an individual must meet: (i) the
financial eligibility criteria; and (ii) the clinical or program eligibility criteria for the General Fund State (GFS) . For
services in which medical necessity criteria applies, all services must be medically necessary.
g. Eligibility criteria for non -crisis behavioral health services funded by GFS areas follows:
i. Not qualify for Medicaid.
ii. Individuals who have a gross monthly income (adjusted for family size) that does not exceed 220% of
the Federal Poverty Guidelines,
iii. And meet one of the following criteria:
1. Are uninsured
2. Have insurance, but are unable to meet the co -pay or deductible for services
3. Are using excessive SLID or mental health crisis services due to inability to access non -crisis
behavioral health services
4. Have more than 5 visits over 6 months to the emergency department, withdrawal
management facility, or the sobering center due to a SLID
(17) Facility may offer a sliding scale fee schedule to Individuals who are not eligible for Medicaid coverage that takes into
consideration an Individual's circumstances and ability to pay. If the Facility selects to develop a fee schedule, the fee
schedule must comply with the following and must be reviewed and approved by Beacon:
a. Put the sliding fee schedule in writing that is non-discriminatory;
b. Include language in the sliding fee schedule that no Individual shall be denied services due to inability to pay;
c. Provide signage and information to Individuals to educate them on the sliding fee schedule;
d. Protect Individual's privacy in assessing fees;
e. Maintain records to account for each Individual's visit and any charges incurred;
f. Charge Individuals at or below 100 percent of Federal Poverty Level (FPL) a nominal fee or no fee at all. The
Federal Poverty Guidelines can be found at hftps://asl)e.hhs.gov/poverty-guidelines.
g. Develop at least three (3) incremental amounts on the sliding fee scale for Individuals between 101 to 220
percent FPL.
h. Facility will reduce the amount billed to Beacon by any sliding fee schedule amounts collected from Eligible
Individuals
I. .
(18) In compliance with RCW 71.32 pertaining to mental health advance directive for behavioral healthcare, Facility shall:
a. Inform all individuals of their right to a mental health advance directive and provide technical assistance to those
who express an interest in developing and maintaining a mental health advance directive
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b. Maintain current copies of any mental health advance directive in the individual's utilization records.
c. Inform individuals that complaints concerning noncompliance with a mental health advance directive should be
referred to the Washington State Department of Health by calling 1-360-236-2620 or by following the written
instructions contained in the mental health benefit booklet.
(19) The Facility shall implement a Grievance process that complies with WAC 182-538C-110. The Facility shall:
a. Inform Individuals of their right to file a Grievance or Appeal in the case of:
i. Denial or termination of service related to medical necessity determinations
ii. Failure to act upon a request for services with reasonable promptness
b. Ensure that termination of this contract shall not be grounds for an Appeal, Administrative Hearing, or a
Grievance for individuals if similar services are immediately available in the service area.
(20) The Facility shall assure equal access for all individuals served when oral or written language creates a barrier to such
access for those with communication barriers consistent with WAC 246-341-0600. This includes the provision of
interpreters for Individuals who are Deaf, DeafBlind, or Hard of Hearing. This includes oral interpretation Sign Language
(SL), and the use of Auxiliary Aids and Services as defined in (42 C.F.R. § 438.10(d)(4)).
(21) The Facility shall ensure that the offer hours of operation for individuals served under this contract with Beacon are no
less than the hours of operation offered to any other individual.
(22) If the Facility is a faith -based organization (FBO), it shall meet the requirements of 42 CFR Part 54 as follows:
a. Individuals requesting or receiving SUD services shall be provided with a choice of SLID treatment providers.
b. The FBO shall facilitate a referral to an alternative provider within a reasonable time frame when requested by
the recipient of services. The FBO shall report to the Contractor all referrals made to alternative providers.
c. The FBO shall provide individuals served with a notice of their rights.
d. The FBO provides individuals served with a summary of services that includes any inherently religious activities.
e. Funds received from the FBO must be segregated in a manner consistent with federal regulation
f. No funds may be expended for religious activities
(23) Facility shall ensure that all services and activities provided under this Agreement shall be designed and delivered in a
manner sensitive to the needs of the diverse population. Additionally, Facility shall initiate actions to ensure or improve
access, retention, and cultural relevance of treatment, prevention or other appropriate services, for ethnic minorities and
other diverse populations in need of services under this Agreement as identified in their needs assessment.
(24) Reporting.
a. Facility must collect and report to Beacon all applicable transactions described in the Department of Social and
Health Services (DSHS) most current Behavioral Health Data System (BHDS) Data Guide.
b. Facility shall comply with all critical incidents reporting in accordance with WAC 246-341-0200, 246-341-0365,
246-341-0410, and 246-341-0420. All critical incidents shall be reported within 1 business day of becoming
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aware of the incident.
(25) For providers in twenty-four (24) hour settings, a requirement to provide discharge planning services which shall, at a
minimum:
a. Coordinate a community-based discharge plan for each individual served under this Agreement beginning at
intake in order to procure the best available recovery plan and environment for the individual. Discharge planning
shall apply to all individuals regardless of length of stay or whether they complete treatment.
b. Coordinate exchange of assessment, admission, treatment progress, and continuing care information with the
referring entity. Contact with the referral agency shall be made within the first week of residential treatment.
c. Establish referral relationships with assessment entities, outpatient providers, vocational or employment
services, and courts which specify aftercare expectations and services, including procedure for involvement of
referents in treatment activities.
d. Coordinate, as needed, with Department of Behavioral Health and Rehabilitation (DBHR) prevention services,
vocational services, housing services and supports, and other community resources and services that may be
appropriate, including the Division of Children and Family Services, the Community Services Division including
Community Service Offices (CSOs).
e. Coordinate services to financially -Eligible Individuals who are in need of medical services.
(26) Performance Evaluation. Beacon shall:
a. At its discretion, upon reasonable notice during normal business hours, perform periodic programmatic and
financial reviews. These may include on-site inspections and audits by Beacon or its agents of the records of
Provider relating to the provision of contracted services.
b. Provide reasonable notice to Provider prior to any on-site visit to conduct an audit, and further notify Provider of
any records Beacon wishes to review.
c. Review and evaluate Provider for its successful performance of all contractual obligations and its compliance
with the terms of the Agreement.
Inform Provider of the results of any performance evaluations and of any dissatisfaction with Provider's
performance, and reserve the right to demand a corrective action plan or to terminate the Agreement.
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Exhibit 113•10.A8
Mental Health Block Grant Program Provisions
This Exhibit contains additional provisions applicable to Covered Services rendered to Eligible Individuals (as defined below)
covered under Mental Health Block Grant (MHBG) Program (as defined below) offered and/or administered by Washington State
Health Care Authority (HCA). In the event of any conflict between the provisions of the Agreement (including Exhibit 68), and this
Exhibit B-10 and subject to the provisions set out in Exhibit B-10, the provisions of this Exhibit control as related to services rendered
to individuals receiving Mental Health Block Grant (MHBG) Program services.
I: General Provisions.
(1) Whenever in this Exhibit B-10 the term "Facility" is used to describe an obligation or duty, such obligation or duty will also
be the responsibility of each individual licensed health care practitioner, Facility, and provider employed or owned by or
under contract with Facility, as the context may require.
(2) Facility agrees:
a. The Facility shall inform, post, and guarantee that each Individual has the following rights in compliance with
WAC 246-341-0600:
i. To information regarding the Individual's behavioral health status.
ii. To receive all information regarding behavioral health treatment options including any alternative or
self-administered treatment, in a culturally -competent manner.
iii. To receive information about the risks, benefits, and consequences of behavioral health treatment
(including the option of no treatment).
iv. To participate in decisions regarding his or her behavioral health care, including the right to refuse
treatment and to express preferences about future treatment decisions.
v. To be treated with respect and with due consideration for his or her dignity and privacy.
vi. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience,
or retaliation.
vii. To request and receive a copy of his or her medical records, and to request that they be amended or
corrected, as specified in 45 C.F.R. Part 164.
viii. To be free to exercise his or her rights and to ensure that to do so does not adversely affect the way
the Facility treats the Individual.
b. The Facility shall ensure Individual self-determination by:
i. Obtaining informed consent prior to treatment from Individuals, or persons authorized to consent on
behalf of an Individual, as described in RCW 7.70.065;
ii. Complying with the provisions of the Natural Death Act (Chapter 70.122 RCW) and state rules
concerning Advance Directives (WAC 182-501-0125); and,
iii. When appropriate, informing Individuals of their right to make anatomical gifts (Chapter 68.64 RCW).
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c. Follow all rules and regulations of CFDA 93.958 for provision of services for the Block Grants for Community
Mental Health (MHBG) program.
II: Definitions.
(1) Cultural Humility: The continuous application in professional practice of self -reflection and self -critique, learning from
patients, and partnership building, with an awareness of the limited ability to understand the patient's worldview, culture(s),
and communities.
(2) Culturally Appropriate Care: Health care services provided with Cultural Humility and an understanding of the patient's
culture and community, and informed by Historical Trauma and the resulting cycle of Adverse Childhood Experiences
(ACEs).
(3) Eligible individuals: For purposes of this Exhibit B-10, Eligible Individual means any non -Medicaid individual eligible to
receive services through the MHBG Program offered by the Washington State Health Care Authority and for MHBG
services not covered by Medicaid, any Medicaid individual.
(4) Mental Health Block Grant (MHBG): Means those funds granted by the Secretary of the Department of Health and Human
Services (DHHS), through the Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services
Administration (SAMHSA), to states to establish or expand an organized community-based system for providing mental
health services for adults with Serious Mental Illness (SMI) and children who are seriously emotionally disturbed (SED).
(5) Mental Health Block Grant (MHBG) Program: The program is the provision of those MHBG services further described
within this Exhibit B-10 which are reimbursable pursuant to the contract between Beacon and the Washington State Health
Care Authority.
III: Accountability & Oversight.
(1) Regardless of any provision to the contrary, Washington State Health Care Authority (herein also referred to as 'Payor')
or their respective designees, oversee and monitor the provision of services to individuals on an on-going basis and remain
accountable and responsible for compliance with the terms and conditions of their respective Contract, regardless of the
provisions of the Agreement or any delegation of administrative activities or functions to Beacon.
IV. Compliance.
(1) Comply with all applicable state and federal laws, rules, and regulations related to services rendered to Eligible Individuals,
and applicable requirements of the Beacon and Washington State Health Care Authority Contract.
(2) Comply with Beacon's Program Integrity requirements and HCA approved Program Integrity policies and procedures.
(3) Implement procedures to screen employees, contractors, subcontractors, volunteers, and Board of Directors to ensure
individuals are not excluded from participation in Federal programs. Screening will be completed upon hire and monthly
thereafter.
a. Facility agrees to immediately disclose to Beacon Health Options any exclusion or other event which makes
them ineligible to perform work related directly or indirectly to Federal health care programs.
b. Facility will submit a completed monthly attestation regarding exclusionary checks to Beacon Health Options no
later than the 10th of each month.
c. Facility will make evidence of monthly checks available upon request.
(4) Guard against Fraud, Waste and Abuse by creating a Compliance Plan that includes:
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a. Implementing written policies, procedures and standards of conduct, including whistleblower protection
b. Designating a Compliance Officer and Compliance Committee
c. Conducting effective ongoing training and education of employees and volunteers
d. Developing effective lines of communication
e. Enforcing standards though well-publicized disciplinary guidelines
f. Conducting intemal monitoring and auditing
g. Responding promptly to detected offenses and developing corrective actions;
(5) Participate in Beacon required or HCA sponsored Quality Improvement activities.
(6) Provide Beacon and/or Payors with timely access to records, information and data necessary for Beacon and/or Payors
to meet their respective obligations under their Contract;
(7) Submit all reports and clinical information required by Beacon and/or Payors that may be required by Contract(s) and to
ensure the quality, appropriateness and timeliness of contracted services;
(8) Notify Beacon when a Washington State entity performs any audit related to the activities contained in this contract, and
submit any report and corrective action plan related to the audit to Beacon.
V. Services. Facility agrees to:
(1) Ensure that all services and activities provided under this Contract shall be designed and delivered in a manner
sensitive to the needs of the diverse population.
(2) Initiate actions to develop or improve access, retention, and cultural relevance of treatment, relapse prevention or
other appropriate services, for ethnic minorities and other diverse populations in need of services under this Contract
as identified in their needs assessment.
(3) Participate in training when requested by the HCA. Exceptions must be in writing and include a plan for how the
required information shall be provided to staff.
(4) Facility will use Beacon's Provider Connects portal to register Eligible Individuals for services, including but not
limited to appropriate start date and fund assignment, to ensure they are assigned a unique ID.
a. Funding registration ends after one year. Individuals continuing to receive services must be re -registered.
(5) Provide interpreter services free of change for Individuals with a preferred language other than English. This includes
the provision of interpreters for Individuals who are Deaf, DeafBlind, or Hard of Hearing. This includes oral interpretation
Sign Language (SL), and the use of Auxiliary Aids and Services as defined in (42 C.F.R. § 438.10(d)(4)).
(6) Beacon is the payor of last resort, therefore Facility agrees to:
a. Make reasonable efforts to determine K individuals being served have insurance or health coverage other than
through Payor, including conducing a benefit inquiry in the ProviderOne system, and promptly report any
duplicate coverage to Beacon;
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b. Ensure that services and benefits available under this Contract shall be secondary to all other coverage
c. Attempt to recover any third -party resources available to individuals, including pursuit of FFS Medicaid funds
provided for AI/AN Individuals who did not opt into managed care, and make all records available for audit and
review
(7) Facility may use block grant funds to help Individuals satisfy cost-sharing requirements for MHBG-authorized mental
health services. The Facility must ensure that:
a. The provider is a recipient of block grant funds;
b. Cost-sharing is for a block grant authorized service;
c. Payments are in accordance with MHBG laws and regulations;
d. Cost-sharing payments are made directly to the provider of the service; and
e. A report is provided to Beacon upon request that identifies:
i. The number of Individuals provided cost-sharing assistance;
ii. The total dollars paid out for cost-sharing; and
iii. Providers who received cost-sharing funds.
(8) Facility shall use the Integrated Co -Occurring Disorder Screening Tool (GAIN -SS found at https://www.hca.wa.gov/billers-
providers-partners/behavioral-health-recovery/gain-ss) and shall train staff that will be using the tool(s) to address the
screening and assessment process, the tool, and quadrant placement. Failure to implement and maintain the process
may result in corrective action.
(9) Deliver MHBG services as described in the regional MHBG Project Plan for the current fiscal year approved by Beacon
and the Health Care Authority.
(10) Provide MHBG services to promote recovery for an adult with a SMI and resiliency for SED children in accordance with
federal and state requirements.
(11) Ensure that MHBG funds are used only for services to individuals who are not enrolled in Medicaid or for services that are
not covered by Medicaid as described in the following table:
Benefits
Services
Use MHBG Funds
Use Medicaid
Individual is not a Medicaid
recipient
Any Allowable Type
Yes
No
Individual is a Medicaid
recipient
Allowed under Medicaid
No
Yes
Individual is a Medicaid
Not Allowed under
recipient
Medicaid
Yes
No
(12) MHBG funds cannot be used for the following:
a. Inpatient mental health services.
b. Construction and/or renovation.
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c. Capital assets or the accumulation of operating reserve accounts.
d. Equipment costs over $5,000.
e. Cash payments to Consumers
f. Grant funds may not be used, directly or indirectly, to purchase, prescribe, or provide marijuana or treatment
usingmarijuana. Treatment in this context includes the treatment ofopioid use disorder. Grant funds also cannot
be provided to any individual who or organization that provides or permits marijuana use for the purposes of
treating substance use or mental disorders. See, e.g., 45 C.F.R. § 75.300(a) (requiring HHS to "ensure that
Federal funding is expended... in full accordance with U.S. statutory... requirements."); 21 U.S.C. §§ 812(c) (10)
and 841 (prohibiting the possession, manufacture, sale, purchase or distribution of marijuana). This prohibition
does not apply to those providing such treatment in the context of clinical research permitted by the DFA and
under the FDA -approved investigational new drug application where the article being evaluated is marijuana or
a constituent thereof that is otherwise a banned substance under federal law.
(13) MHBG funds may not be used to pay for services provided prior to the execution of this Exhibit, or to pay in advance of
service delivery. All contracts and amendments must be in writing and executed by both parties prior to any services being
provided.
(14) Participate in annual peer review by individuals with expertise in the field of mental health treatment when requested by
HCA (42 U.S.C. 300x-53 (a) and 45 C.R.R. 96.136, MHBG Service Provisions).
(15) Send a representative to the regional Behavioral Health Advisory Board (BHAB) meetings to report on program data and
results.
VI. Reporting Requirements. Reporting requirements include, but are not limited to, the following:
(1) Facility must submit complete and accurate reports and data required under this Exhibit, including encounter data that
complies with HCA Service Encounter Reporting Instructions (SERI) Guide, HCA Encounter Data Reporting Guide
(EDRG), and Behavioral Health Supplemental Transactions that complies with the Behavioral Health Data System
(BHDS) Guide.
(2) Facility must provide claims and/or encounter codes to Beacon for reporting to the Washington State Health Care Authority
in accordance with the Rate Schedules in this Contract. Claims submitted for health care payments, also known as the
Fee for Service (FFS) payment type, must be submitted within current Washington State Health Care Authority timely
filing requirements or they will be denied for timely filing. Encounters submitted for health care reporting purposes, also
known as the Prepaid payment type, must be submitted to Beacon monthly by the 151h each month. Claims and encounter
submissions are used to reconcile services provided and directly impact future rate setting and/or funding available in the
RSA. Failure to submit claims and/or encounters for services rendered as outlined in your rate schedule(s) may result in
future budget reductions.
(3) Facility must collect and report to Beacon all applicable transactions described in the Department of Social and Health
Services (DSHS) most current Behavioral Health Data System (BHDS) Guide
(4) Unless there is an established SFTP site with Beacon, reports should be submitted to the following email address, which
is monitored multiple times each day: BeaconWAASO(Dbeaconhealthoptions.com.
a. The name of the report should be included in the email subject line.
(5) Facility will submit a completed monthly attestation regarding exclusionary checks to Beacon Health Options no later than
the 10th of each month.
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(6) Using the template provided by Beacon, the Facility shall submit a Monthly MHBG Performance Report by the 10th of
each month:
(7) Provide any additional reporting as detailed in the block grant plan.
(8) Using the template provided by Beacon, the Contractor shall submit an Annual MHBG Performance Report 2 weeks prior
to the HCA due date of each contract year detailing:
a. All performance outcomes met or unmet, including applicable supporting data
b. Barriers encountered and steps taken to remove barriers
c. Lessons learned with recommendations to improve upon future service outcomes
(9) Any other reports deemed necessary by Beacon to meet its reporting requirements pursuant to the terms of its agreement
with the Washington State Health Care Authority and deemed necessary by Beacon to meets its requirements to ensure
quality of care and services provided to Eligible Individuals.
(10) Failure to meet reporting requirements may result in a Corrective Action Plan (CAP).
VII. Documents Incorporated by Reference.
(1) Each of the documents listed below are incorporated by this reference into this Exhibit B-10 as though fully set forth herein,
including any amendments, modifications or supplements thereto. All services shall be provided in accordance with these
documents and legal authorities:
a. Beacon's contracts, program agreements, exhibits, amendments, and any other agreements with the
Washington State Health Care Authority;
b. The Medicaid State Plan and the 1915(b) Medicaid Waiver;
c. The Health Care Authority policies, the State Medicaid Manual (SMM) as applicable, the BARS Manual and any
applicable BARS Supplemental Instructions;
d. State laws and regulations including the Revised Code of Washington and the Washington Administrative Code;
e. Beacon External Policies and Procedures, including Beacon's Provider Handbook and Washington State ASO
Provider Handbook: Supplemental Appendix;
f. CPT Manual, HCPC Manual, and Washington State Service Encounter Reporting Instructions;
g. The Code of Federal Regulations Title 45 CFR and Title 42 CFR; and,
h. Title XIX of the Social Security Act.
VIII. Term & Termination.
(1) In addition to and notwithstanding the provisions set forth in the Agreement, this Exhibit maybe suspended or terminated
by Beacon immediately upon written notice if:
a. Facility is disqualified, terminated, suspended, debarred, or otherwise excluded from or ineligible for participation
under the program or any other state or federal government-sponsored health program; or
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b. The Agreement is terminated or not renewed.
IX. Confidential Information.
(1) Nothing contained in the Beacon Facility Agreement or associated exhibits shall be construed as prohibiting Facility from
sharing information with the public as required by federal, state or local law.
X. Provider Communication.
(1) Nothing under this Agreement prohibits, or otherwise restricts, a health care professional acting within the lawful scope of
practice, from advising or advocating on behalf of an individual who is his or her patient, for the following:
a. The individual's health status, medical care, or treatment options, including any alternative treatment that may
be self-administered.
b. Any information the individual needs in order to decide among all relevant treatment options.
c. The risks, benefits, and consequences of treatment or non -treatment.
d. The individual's right to participate in decisions regarding his or her health care, including the right to refuse
treatment, and to express preferences about future treatment decisions.
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Exhibit B -11.A8
Substance Use Disorder Program Provisions
This Exhibit contains additional provisions applicable to Covered Services rendered to Eligible Individuals (as defined below)
covered under Substance Use Disorder (SUD) Program (as defined below) offered and/or administered by Washington State Health
Care Authority (HCA). In the event of any conflict between the provisions of the Agreement (including Exhibit B8), and this Exhibit
B-11 and subject to the provisions set out in Exhibit B-11, the provisions of this Exhibit control as related to services rendered to
individuals receiving SUD Program services.
I: General Provisions.
(1) Whenever in this Exhibit B-11 the term "Facility" is used to describe an obligation or duty, such obligation or duty will also
be the responsibility of each individual licensed health care practitioner, Facility, and provider employed or owned by or
under contract with Facility, as the context may require.
(2) Facility agrees:
a. The Facility shall inform, post, and guarantee that each Individual has the following rights in compliance with
WAC 246-341-0600:
i. To information regarding the Individual's behavioral health status.
ii. To receive all information regarding behavioral health treatment options including any alternative or
self-administered treatment, in a culturally -competent manner.
iii. To receive information about the risks, benefits, and consequences of behavioral health treatment
(including the option of no treatment).
iv. To participate in decisions regarding his or her behavioral health care, including the right to refuse
treatment and to express preferences about future treatment decisions.
v. To be treated with respect and with due consideration for his or her dignity and privacy.
vi. To be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience,
or retaliation.
vii. To request and receive a copy of his or her medical records, and to request that they be amended or
corrected, as specified in 45 C.F.R. Part 164.
viii. To be free to exercise his or her rights and to ensure that to do so does not adversely affect the way
the Facility treats the Individual.
b. The Facility shall ensure Individual self-determination by:
i. Obtaining informed consent prior to treatment from Individuals, or persons authorized to consent on
behalf of an Individual, as described in RCW 7.70.065;
ii. Complying with the provisions of the Natural Death Act (Chapter 70.122 RCW) and state rules
concerning Advance Directives (WAC 182-501-0125); and,
iii. When appropriate, informing Individuals of their right to make anatomical gifts (Chapter 68.64 RCW).
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c. Facility shall provide substance use disorder services in accordance with the Beacon Level of Care Guidelines
and under the Beacon Service Instruction Manual, which are incorporated herein by reference.
d. Follow all rules and regulations of CFDA 93.959 for provision of services for the Substance Abuse Prevention
and Treatment Block Grant (SABG) program when funding is used.
e. Facility shall provide alcohol and drug treatment services per RCW 70.96A as described in the Services below.
f. If applicable, Facility shall provide alcohol and drug treatment services pursuant to the Dedicated Marijuana
Account DMA program provisions as promulgated by the Washington State Health Care Authority when that
funding is used.
i. DMA funds shall be used to fund SLID treatment services for youth living at or below 220 percent of the
federal poverty level, without insurance coverage or who are seeking services independent of their
parent/guardian;
ii. DMA funds may be used for development, implementation, maintenance, and evaluation of programs
that support intervention, treatment, and Recovery Support Services for middle school and high school
aged students.
g. If applicable, provide Outpatient Treatment Services in accordance with WAC 246-341 for Specialty Court or
CJTA eligible patients. Specifically, Facility shall:
i. Provide alcohol and drug treatment and treatment support services per RCW 70.96A when CJTA
funding is utilized.
ii. Provide services to individuals with an addiction or a substance abuse problem that, if not treated,
would result in addiction, against whom a prosecuting attorney in Washington State has filed charges.
iii. Provide alcohol and drug treatment services and treatment support services to nonviolent offenders
within a drug court program as defined in RCW 70.96A.056 and RCW 2.28.170.
iv. In accordance with RCW 2.30.040, if CJTA funds provided support for, or associated services by a
Therapeutic Court, then the county is required to provide a dollar -for -dollar participation match for
services to Individuals who are receiving services under the supervision of a Therapeutic Court.
1. No more than 10 percent of the total CJTA funds can be used for the following treatment
support services combined:
a. Transportation; and
b. Child Care Services.
v. Per RCW 71.24.580, "If a region or county uses Criminal Justice Treatment Account funds to support
a therapeutic court, the therapeutic court must allow the use of all medications approved by the federal
FDA for the treatment of opioid use disorder as deemed medically appropriate for a participant by a
medical professional. If appropriate medication -assisted treatment resources are not available or
accessible within the jurisdiction, the HCA's designee for assistance must assist the court with acquiring
the resource."
If: Definitions.
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(1) Acute Withdrawal Management: Means services provided to an Individual to assist in the process of withdrawal from
psychoactive substance in a safe and effective manner, Medically monitored withdrawal management provides medical
care and physician supervision for withdrawal from alcohol or other drugs.
(2) American Society of Addiction Medicine Level of Care Guidelines (ASAM Guidelines): Means a professional society
dedicated to increasing access and improving the quality addiction treatment. ASAM Guidelines are a set of criteria
promulgated by ASAM used for determining treatment placement, continued stay and transfer/discharge of individuals
with addiction conditions.
(3) Brief Intervention for SUD: Means a time limited, structured behavioral intervention using techniques such as evidence -
based motivational interviewing, and referral to treatment services when indicated. Services may be provided at sites
exterior to treatment facilities such as hospitals, medical clinics, schools or other non-traditional settings.
(4) Certified Peer Counselor (CPC): Means individuals that have met the requirements to help individuals and families
identify goals that promote Recovery and resiliency and help to identify services and child care activities to reach these
goals.
(5) Criminal Justice Treatment Account (CJTA): Means an account created by the state for expenditure on: a) SUD
treatment and treatment support services for offenders with a SUD that, if not treated, would result in addiction, against
whom charges are filed by a prosecuting attorney in Washington State; b) the provision of drug and alcohol treatment
services and treatment support services for nonviolent offenders within a drug court program (RCW 71,24.580 and
RCW 2.30.030)..
(6) Cultural Humility: The continuous application in professional practice of self -reflection and self -critique, learning from
patients, and partnership building, with an awareness of the limited ability to understand the patient's worldview, culture(s),
and communities.
(7) Culturally Appropriate Care: Health care services provided with Cultural Humility and an understanding of the patient's
culture and community, and informed by Historical Trauma and the resulting cycle of Adverse Childhood Experiences
(ACEs).
(8) Eligible Individuals: For purposes of this Exhibit B-11, Eligible Individual means any non -Medicaid individual eligible to
receive services through the SUD Program offered by the Washington State Health Care Authority, and for SABG funded
services not covered by Medicaid, any Medicaid individual.
(9) Engagement & Outreach: Engagement is a strategic set of activities that are implemented to develop an alliance with an
individual for the purpose of bringing them into or keeping them in ongoing treatment. The activities occur primarily in the
field rather the worker's office, or at another service agency such as food bank or public shelter, or via telephone if a
potential individual calls the workers office seeking assistance or by referral.
(10) Interim Services: Means services to individuals who are currently waiting to enter a treatment program to reduce the
adverse health effects of substance abuse, promote the health of the individual, and reduce the risk of transmission of
disease.
(11) Inpatient/Residential Substance Use Treatment Services: Means rehabilitative services, including diagnostic evaluation
and face-to-face individual or group counseling using therapeutic techniques directed toward Individuals who are harmfully
affected by the use of mood -altering chemicals or have been diagnosed with a Substance Use Disorder (SUD).
Techniques have a goal of abstinence (assisting in their Recovery) for Individuals with SUDs. Provided in certified
residential treatment facilities with sixteen (16) beds or less. Residential treatment services require additional program -
specific certification by DOH, and include: Intensive inpatient services; Recovery house treatment services; Long-term
residential treatment services; and Youth residential services.
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(12) Intensive Inpatient Residential Services: Means a concentrated program of SLID treatment, individual and group
counseling, education, and related activities including room and board in a 24 -hour -a -day supervised Facility in
accordance with Chapter 246.341 WAC (The service as described satisfies the level of intensity in ASAM Level 3.5)
(13) Intensive Outpatient SLID Treatment: means services provided in a non-residential intensive patient centered outpatient
program for treatment of SUD (The service as described satisfies the level of intensity in ASAM Level 2.1).
(14) Long -Term Care Residential SUD Services: Means the care and treatment of chronically impaired individuals diagnosed
with substance use disorder with impaired self -maintenance capabilities including personal care services and a
concentrated program of substance use disorder treatment, individual and group counseling, education, vocational
guidance counseling and related activities for individuals diagnosed with substance use disorder, excluding room and
board in a twenty -four -hour -a -day, supervised facility accordance with WAC 246-341-1114. (The service as described
satisfies the level of intensity in ASAM Level 3.3.)
(15) Medically Necessary Services: A requested service which is reasonably calculated to prevent, diagnose, correct, cure,
alleviate, or prevent worsening of conditions in the Individual that endanger life, cause suffering of pain, result in an illness
or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction. There is no other
equally effective, more conservative or substantially less costly course of treatment available or suitable for the client
Individual requesting the service. "Course of treatment" may include mere observation or, where appropriate, no treatment
at all
(16) Medication Assisted Treatment (MAT): Means the use of medications, in combination with counseling and behavioral
therapies, to provide a whole -patient approach to the treatment of SUDS.
(17) Opioid Substitution Treatment: Means assessment and treatment to opioid dependent patients. Services include
prescribing and dispensing of an approved medication, as specified in 212 CFR Part 291, for opioid substitution services
in accordance with WAC 246-341-1000 through 246-341-1025. Both withdrawal management and maintenance are
included, as well as physical exams, clinical evaluations, individual or group therapy for the primary patient and theirfamily
or significant others. Additional services include guidance counseling, family planning and educational and vocational
information. (The service as described satisfies the level of intensity in ASAM Level 1).
(18) Pregnant and Post -Partum Women (PPW): Means: (i) women who are pregnant; (ii) women who are postpartum during
the first year after pregnancy completion regardless of the outcome of the pregnancy or placement of children; or (iii)
women who are parenting children, including those attempting to gain custody of children supervised by the Department
of Children, Youth and Families (DCYF).
(19) Pregnant, Post -Partum or Parenting (PPW) Women's Housing Support Services: Means the costs incurred to provide
support services provided to PPW individuals with children under the age of six (6) in a transitional residential housing
program designed exclusively for this population.
(20) Recovery House Residential Treatment: Means a program of care and treatment with social, vocational, and recreational
activities designed to aid individuals diagnosed with substance use disorder in the adjustment to abstinence (assisting in
their Recovery) and to aid in job training, reentry to employment, or other types of community activities, excluding room
and board in a twenty-four-hour-aday supervised facility in accordance with WAC 246-341. (The service as described
satisfies the level of intensity in ASAM Level 3.1).
(21) Recovery Support Services: Means a broad range of non -clinical services that assist individuals and families to initiate,
stabilize, and maintain long-term Recovery from behavioral health disorders including mental illness and substance use
disorders.
(22) Sobering Services: Means short-term (12 hours or less) emergency shelter, screening, and referral services to persons
who are intoxicated or in active withdrawal. .
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(23) Sub -Acute Withdrawal Management (Detoxification): Means services provided to an individual to assist in withdrawal
from psychoactive substance in a safe and effective manner. Sub -Acute is nonmedical detoxification/withdrawal
management or patient self -administration of withdrawal medications ordered by a physician, provided in a home -like
environment.
(24) Substance Abuse Block Grant (SABG) Block Grant: Means the Federal Substance Abuse Block Grant Program
authorized by Section 1921 of Tifie XIX, Part B, Subpart II and III of the Public Health Service Act.
(25) Substance Use Disorder Outpatient Treatment: Means services provided in a non-residential substance use disorder
treatment facility. Outpatient treatment services must meet the criteria in Chapter 246-341 WAC. (The service as
described satisfies the level of intensity in ASAM Level 1).
(26) Substance Use Disorder Professional (SUDP): Means an individual who is certified according to chapter 18.205 RCW
and the certification requirements of WAC 246-811-030 to provide Substance Use Disorder (SUD) services.
(27) Substance Use Disorder (SUD) Program: The program is the provision of those SUD services further described within
this Exhibit B-11 which are reimbursable pursuant to the contract between Beacon and the Washington State Health Care
Authority.
(28) Youth: Means a person from age ten (10) through seventeen (17). However, under SABG, Youth Support Services can
be billed for individuals through age twenty (20) if the individual is not developmentally living as adults after age eighteen
(18).
(29) Waiting List: Means a list of Eligible Individuals who qualify for SABG-funded services for whom services have not been
scheduled due to lack of capacity.
III: Accountability & Oversight.
(1) Regardless of any provision to the contrary, Washington State Health Care Authority (herein also referred to as'Payor')
or their respective designees, oversee and monitor the provision of services to individuals on an on-going basis and remain
accountable and responsible for compliance with the terms and conditions of their respective Contract, regardless of the
provisions of the Agreement or any delegation of administrative activities or functions to Beacon.
IV. Compliance.
(1) Comply with all applicable state and federal laws, rules, and regulations related to services rendered to Eligible Individuals,
and applicable requirements of the Beacon and Washington State Health Care Authority Contract.
(2) Comply with Beacon's Program Integrity requirements and HCA approved Program Integrity policies and procedures.
(3) Implement procedures to screen employees, contractors, subcontractors, volunteers, and Board of Directors to ensure
individuals are not excluded from participation in Federal programs. Screening will be completed upon hire and monthly
thereafter.
a. Facility agrees to immediately disclose to Beacon Health Options any exclusion or other event which makes
them ineligible to perform work related directly or indirectly to Federal health care programs.
b. Facility will submit a completed monthly attestation regarding exclusionary checks to Beacon Health Options no
later than the 10th of each month.
c. Facility will make evidence of monthly checks available upon request.
(4) Guard against Fraud, Waste and Abuse by creating a Compliance Plan that includes:
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a. Implementing written policies, procedures and standards of conduct, including whistleblower protection
b. Designating a Compliance Officer and Compliance Committee
c. Conducting effective ongoing training and education of employees and volunteers
d. Developing effective lines of communication
e. Enforcing standards though well-publicized disciplinary guidelines
f. Conducting internal monitoring and auditing
g. Responding promptly to detected offenses and developing corrective actions;
(5) Participate in Beacon required or HCA sponsored Quality Improvement activities.
(6) Provide Beacon and/or Payors with timely access to records, information and data necessary for Beacon and/or Payors
to meet their respective obligations under their Contract;
(7) Submit all reports and clinical information required by Beacon and/or Payors that may be required by Contract(s) and to
ensure the quality, appropriateness and timeliness of contracted services;
(8) Notify Beacon when a Washington State entity performs any audit related to the activities contained in this contract, and
submit any report and corrective action plan related to the audit to Beacon.
V. Services. Facility agrees to:
(1) Ensure that all services and activities provided under this Contract shall be designed and delivered in a manner
sensitive to the needs of the diverse population.
(2) Initiate actions to develop or improve access, retention, and cultural relevance of treatment, relapse prevention or
other appropriate services, for ethnic minorities and other diverse populations in need of services under this Contract
as identified in their needs assessment.
(3) Participate in training when requested by the HCA. Exceptions must be in writing and include a plan for how the
required information shall be provided to staff.
(4) Facility will use Beacon's Provider Connects portal to register Eligible Individuals for services, including but not
limited to appropriate start date and fund assignment, to ensure they are assigned a unique ID.
a. Funding registration ends after one year. Individuals continuing to receive services must be re -registered.
(5) Provide interpreter services free of change for Individuals with a preferred language other than English. This includes
the provision of interpreters for Individuals who are Deaf, DeafBlind, or Hard of Hearing. This includes oral interpretation
Sign Language (SL), and the use of Auxiliary Aids and Services as defined in (42 C.F.R. § 438.10(d)(4)).
(6) Beacon is the Payor of last resort, therefore Facility agrees to:
a. Make reasonable efforts to determine if individuals being served have insurance or health coverage other than
through Payor, including conducing a benefit inquiry in the ProviderOne system, and promptly report any
duplicate coverage to Beacon;
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b. Ensure that services and benefits available under this Contract shall be secondary to any other coverage
c. Attempt to recover any third -party resources available to individuals, including pursuit of FFS Medicaid funds
provided for AI/AN Individuals who did not opt into managed care, and make all records available for audit and
review
(7) Facility shall use the Integrated Co -Occurring Disorder Screening Tool (GAIN -SS found at https://www.hca.wa.gov/billers-
providers-partners/behavioral-health-recovery/gain-ss) and shall train staff that will be using the tool(s) to address the
screening and assessment process, the tool, and quadrant placement. Failure to implement and maintain the process
may result in corrective action.
(8) Facility may use block grant funds to help Individuals satisfy cost-sharing requirements for SABG-authorized SUD
services. The Facility must ensure that:
a. The provider is a recipient of block grant funds;
b. Cost-sharing is for a block grant authorized service;
c. Payments are in accordance with SABG laws and regulations;
d. Cost-sharing payments are made directly to the provider of the service; and
e. A report is provided to Beacon upon request that identifies:
i. The number of Individuals provided cost-sharing assistance;
ii. The total dollars paid out for cost-sharing; and
iii. Providers who received cost-sharing funds.
(9) Services in the table below are allowable as defined by the HCA when utilizing funds in the priority identified when that
funding is received. ASAM criteria is used to determine appropriate levels of care. Authorization from a Beacon Care
Manager is required for Withdrawal Management and Residential Treatment. Facilities seeking reimbursement for
providing services without an associated Fee for Service (FFS) billing code in Facility' rate schedule, shall confirm such
services are part of the RSA's current SABG Plan and obtain approval from the RSA's Account Partnership Director before
submission of a cost reimbursement invoice.
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CJTA-Drug Court:
SABG: 1st priority
1st Priority for
DMA: 1st priority
for non -offender
GFS: Default
Service
qualifying
for youth or
adults or services
funding after all
nonviolent
perinatal women
not covered by
others
offender
DMA
Brief Intervention (Any Level,
X
X
X
X
Assessment not Required)
Acute Withdrawal Management
X
X
X
X
ASAM Level 3.7WM
Sub -Acute Withdrawal
Management (ASAM Level
X
X
X
X
3.2WM
Outpatient Treatment (ASAM
X
X
X
X
Level 1
Intensive Outpatient Treatment
X
X
X
X
ASAM Level 2.1
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Service
CJTA-Drug Court:
1st Priority for
qualifying
nonviolent
offender
DMA: 1st priority
for youth or
perinatal women
SABG: 1st priority
for non -offender
adults or services
not covered by
DMA
GFS: Default
funding after all
others
Brief Outpatient Treatment
ASAM Level 1
X
X
X
X
Opioid Substitution Treatment
ASAM Level 1
X
X
X
X
Case Management (ASAM Levels
1,2)
X
X
X
X
Intensive Inpatient Residential
Treatment (ASAM Level 3.5
X
X
X
X
Long-term Care Residential
Treatment (ASAM Level 3.3
X
X
X
X
Recovery House Residential
Treatment (ASAM Level 3.1
X
X
X
X
Assessment
X*
X
X
X
Engagement and Referral
X
X
X
Alcohol/Drug Information School
X
X
X
Opioid Dependency Outreach
X
X
X
X
Interim Services
X
X
X
X
Community Outreach and
Engagement
X
X
X
X
Crisis Services
X
X
Sobering Services
X
X
X
Involuntary Commitment
Investigations and Treatment
X
X
X
Therapeutic Interventions for
Children
X
X
X
Transportation
X
X
X
X
Childcare Services provided by
licensed childcare providers
X
X
X
X
PPW Housing Support Services
X
X
X
Family Hardship
X
Recovery Support Services
X
X
X
X
Continuing Education
X
X
Urinalysis
X
X
X
X
Employment services and job
training
X
X
X
Relapse prevention
X
X
X
X
Family/marriage education
X
X
X
Peer-to-peer services, mentoring
and coaching
X
X
X
X
Self-help and support groups
X
X
X
Housing support services (rent
and/or deposits)
X
X
X
Life skills
X
X
X
Spiritual and faith -based support
X
X
X
Education
X
X
X
Parent education and child
development
X
X
X
*includes assessments done while in jail
(10) If Facility is providing Inpatient Medically Monitored Intensive Inpatient Detoxification Services (Level 3.7), as authorized
by Beacon, the following shall be included:
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a. Must provide 24hd7 days per week medically -monitored services
b. 24-hour nursing care with physician availability
c. Must accept admissions 24hrs/7 days per week.
d. Must have written admission and discharge criteria.
e. Must provide medical diagnostic services on-site or by contract.
f. Must provide a full range of treatment programming 7 days per week.
g. Must provide individualized treatment plans.
h. Must provide emergency psychiatric/medical services on-site or by contract.
i. Must require and/or encourage family involvement in treatment.
j. Must provide structured recovery support groups.
k. Must have an Addictionologist either on staff or contracted or Medical Director must have three (3) years'
experience treating substance abuse patients as evidenced in resume.
I. Must receive oversight from a Medical Director.
(11) If Facility is providing Intensive Outpatient services, the following shall be included:
a. Must have a written program narrative.
b. Must provide individualized treatment plans.
c. Must have written procedures for handling medical/psychiatric emergencies.
d. Must provide or make available any structured recovery support groups.
e. Must have the supervision of a licensed clinician.
f. Must have written admission and discharge criteria.
g. Must have a written schedule of program activities.
h. Must provide services at least 3hrs per day, 3 to 5 days per week.
(12) If Facility is providing Clinically Managed High Intensity Residential Services (Level 3.5), authorized by Beacon, the
following shall be included:
a. Must provide 24hrf7 days per week coverage by licensed staff.
b. Must accept admissions 24hrs(7 days per week.
c. Must have written admission and discharge criteria.
d. Must provide medical diagnostic services on-site or by contract.
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e. Must provide a full range of treatment programming 7 days per week.
f. Must provide individualized treatment plans.
g. Must provide emergency psychiatric/medical services on-site or by contract.
h. Must require and/or encourage family involvement in treatment.
Must provide structured recovery support groups and aftercare.
j. Must have an Addictionologist either on staff or contracted or Medical Director must have three (3) years'
experience treating substance abuse patients as evidenced in resume.
k. Must receive oversight from a Medical Director.
(13) Conduct an inquiry regarding each patient's continued financial eligibility no less than one time per month.
(14) Document the evidence of each financial screening in individual patient records.
(15) For all engagement and outreach services provided prior to an intake, the Facility shall:
a. If more than three engagement and outreach services provided in a 90 -day period to the same person and an
intake has not been provided, the Facility shall ensure a note is included in the chart indicating why individual
has not received an intake.
b. Facility should track outcomes of outreach and engagement in converting individuals into ongoing treatment.
(16) Ensure that, as a Facility receiving funding under the Block Grant and providing services required by CFR Title 45, Section
96.959, Facility shall make every effort, including the establishment of systems for eligibility determination, billing, and
collection, to:
a. Collect reimbursement for the costs of providing such services to persons who are entitled to insurance benefits
under the Social Security Act, including programs under Title XVIII and Title XIX. Additional programs include
any State compensation program, other public assistance program for medical expenses, grant programs,
private health insurance, or any other benefit program; and
b. Secure payments from individuals for services in accordance with their ability to pay.
(17) Meet the needs of priority populations, in priority order below, as identified in the SABG or by HCA, including but not
limited to:
a. Pregnant individuals injecting drugs.
b. Pregnant individuals with SUD.
c. Women with dependent children.
d. Individuals who are injecting drugs or substances.
e. The following additional priority populations, in no particular order:
i. Postpartum women (up to one year, regardless of pregnancy outcome).
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ii. Patients transitioning from residential care to outpatient care.
fffii•'1ex1w
iv. Offenders as defined in RCW 70.96.350.
(18) The Facility shall ensure that all services and activities provided under this Contract shall be designed and delivered in a
manner sensitive to the needs of a diverse population;
(19) The Facility shall initiate actions to ensure or improve access, retention, and cultural relevance of treatment, prevention
or other appropriate services, for ethnic minorities and other diverse populations in need of services under this Contract
as identified in their needs assessment.
(20) For SABG funded services, the Facility shall ensure the following:
a. Within available resources, ensure that SABG services are not denied to any Eligible Individual regardless of:
i. The individual's drug(s) of choice.
ii. The fact that the individual is taking FDA approved medically -prescribed medications.
iii. The fact that the individual is using over the counter nicotine cessation medications or actively
participating in a nicotine replacement therapy regimen
b. Deliver SABG services as described in the regional SABG Project Plan for the current fiscal year approved by
Beacon and the Health Care Authority.
c. Ensure that SABG funds are used only for services to individuals who are not enrolled in Medicaid or for services
that are not covered by Medicaid as described in the following table:
Benefits
Services
Use SABG Funds
Use Medicaid
Individual is not a Medicaid
Any Allowable Type
Yes
No
recipient
Individual is a Medicaid
Allowed under Medicaid
No
Yes
recipient
Individual is a Medicaid
Not Allowed under
recipient
Medicaid
Yes
No
d. Have protocols for maintaining waiting lists and providing interim services for SABG priority population
individuals, as defined in this Contract, who are eligible to receive services but for whom SUD treatment services
are not available due to limitations in provider capacity or available resources.
i. The waiting list interim record must include:
1. Application form that includes the applicant's full name (last, first and middle initial), birth date,
gender, race (including Spanish/Hispanic origin), Social Security Number, address and phone
number
2. A unique individual identifier for each individual
3. Service plan record noting proposed treatment modalities, tentative treatment dates
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4. Record of all contacts and referrals.
e. Ensure interim services are provided by for pregnant and parenting women and intravenous drug users.
f. Interim services shall be made available within forty-eight (48) hours of seeking treatment for pregnant and
parenting women and intravenous drug users.
g. Admission to treatment services for the intravenous drug user shall be provided within fourteen (14) days after
the patient makes the request, regardless of funding source.
h. If there is no treatment capacity within fourteen (14) days of the initial patient request, the Facility shall have up
to one hundred twenty (120) days, after the date of such request, to admit the patient into treatment, while offering
or referring to interim services within forty-eight (48) hours of the initial request for treatment services. Interim
services must be documented in the system platform designated by the HCA and include, at a minimum:
i. Counseling on the effects of alcohol and drug use on the fetus for the pregnant patient.
ii. Prenatal care for the pregnant patient.
iii. Human immunodeficiency virus (HIV) and tuberculosis (TB) education.
iv. HIV or TB treatment services if necessary for an intravenous drug user.
v. The interim service documentation requirement is specifically for the admission of priority populations
with any funding source; and any patient being served with SABG Block Grant funds.
i. A pregnant woman who is unable to access residential treatment due to lack of capacity and is in need of
detoxification, can be referred to a Chemical Using Pregnant (CUP) program for admission, typically within
twenty-four (24) hours.
j. Facility shall notify Beacon, in writing, when the Facility is at ninety (90) percent capacity and must maintain
records using the Capacity Management Form, in accordance with (42 USC 300-23 and 42 USC 30OX 27).
k. On a quarterly basis, on the last day of the month following the close of the quarter, Facility shall submit the
DBHR Capacity Management Form. The Capacity Management Form will identify PPW and IUID providers
receiving SABG funds, who are at (90) percent capacity, and what was or is being done to address capacity.
I. SABG funds cannot be used for the following:
i. Inpatient mental health services.
ii. Construction and/or renovation.
iii. Capital assets or the accumulation of operating reserve accounts.
iv. Equipment costs over $5,000.
v. Cash payments to Consumers
vi. Grant funds may not be used, directly or indirectly, to purchase, prescribe, or provide marijuana or
treatment using marijuana. Treatment in this context includes the treatment of opioid use disorder.
Grant funds also cannot be provided to any individual who or organization that provides or permits
marijuana use for the purposes of treating substance use or mental disorders. See, e.g., 45 C.F.R. §
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75.3OO(a) (requiring HHS to "ensure that Federal funding is expended ... in full accordance with U.S.
statutory... requirements."); 21 U.S.C. §§ 812(c) (10) and 841 (prohibiting the possession, manufacture,
sale, purchase or distribution of marijuana). This prohibition does not apply to those providing such
treatment in the context of clinical research permitted by the DEA and under the FDA -approved
investigational new drug application where the article being evaluated is marijuana or a constituent
thereof that is otherwise a banned substance under federal law.
m. SABG funds may not be used to pay for services provided prior to the execution of this Exhibit, or to pay in
advance of service delivery. All contracts and amendments must be in writing and executed by both parties prior
to any services being provided
n. Participate in annual peer review by individuals with expertise in the field of drug abuse treatment when
requested by HCA (42 U.S.C. 3OOx-53 (a) and 45 C.R.R. 96.136)
o. Send a representative to the regional Behavioral Health Advisory Board (BHAB) meetings to report on program
data and results.
p. Facility shall ensure compliance with tuberculosis screening, testing and referral, in accordance with (42 USC
300x -24(a) and 45 CFR 96.127), in the following manner:
Coordinating with other public entities to make tuberculosis services available to each Eligible Individual
receiving SABG-funded SUD treatment.
The services will include tuberculosis counseling, testing, and providing for or referring infected with
tuberculosis for appropriate medical evaluation and treatment.
iii. In the case of an Eligible Individual in need of treatment service who is denied admission to the
tuberculosis program on the basis of lack of capacity, the Facility will refer the Eligible Individual to
another provider of tuberculosis services.
iv. Contract for case management activities to ensure the Eligible Individuals receive tuberculosis services.
(21) Charitable Choice Requirements of 42 CFR Part 54 are followed and Faith -Based Organizations (FBO) are provided
opportunities to compete with traditional alcohol/drug abuse treatment providers for funding.
a. Contracted FBOs are required to meet the requirements of 42 C.F.R. Part 54 as follows:
i. Eligible Individuals requesting or receiving SUD services shall be provided with a choice of SUD
treatment providers.
ii. The FBO shall facilitate a referral to an alternative Facility within a reasonable time frame when
requested by the recipient of service
iii. The FBO shall report to Beacon all referrals made to alternative providers.
iv. The FBO shall provide Eligible Individuals with a notice of their rights.
v. The FBO provides Eligible Individuals with a summary of services that includes any religious activities.
vi. Funds received from the FBO must be segregated in a manner consistent with federal Regulations.
vii. No funds may be expended for religious activities.
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(22) Youth Support Services can be billed for individuals through age twenty (20) if the individual is not developmentally living
as adults after age eighteen (18).
a. Youth funds may be used for family support services including:
i. Youth group therapy for youth and young adults ages ten (10) through twenty (20).
ii. Services to family of Youth admitted to treatment and costs incurred to provide supervised recreational
activities in conjunction with a SUD outpatient program. Family services must be coded as family
support services and Supervised Therapeutic Recreation must be coded as group therapy.
iii. Youth Individual Therapy for youth and young adults ages 10-20.
iv. This also includes services to family and significant others of persons in treatment and should billed
according to contracted codes.
(23) Prior Authorization is required for all residential patients.
(24) Facility may provide the following services, as authorized by Beacon, using funds from the Designated Marijuana Account
when that funding is used:
a. Substance Use Disorder Outpatient Adolescent Treatment utilizing individual, group and family treatment
modalities
b. Assessment
c. Residential Treatment Services — Adolescent
(25) When CJTA funding is used, Facility shall participate in the development and implementation of any local CJTA plans
developed by the CJTA panel and approved by HCA and/or the CJTA Panel established in 714.24.580(5)(b).
(26) When CJTA funding is used for treatment in the jail:
a. CJTA funding used for this purpose may not supplant any locally funded programs within a city, county, or tribal
jail.
b. SUD treatment service provided in jail may include, but are not necessarily limited to the following:
i. Engaging Individuals in SUD treatment
ii. Referral to SUD services;
iii. Administration of Medications for the treatment of SUDs including Opioid Use Disorder to include the
following
iv. Screening for medications for SUDs
v. Cost of medications for SUDs
vi. Administration of medications for SUDs
c. Coordinating care;
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d. Continuity of Care; and
e. Transition planning
VI. Reporting Requirements. Reporting requirements include, but are not limited to, the following:
(1) Facility must submit complete and accurate reports and data required under this Exhibit, including encounter data that
complies with HCA Service Encounter Reporting Instructions (SERI) Guide, HCA Encounter Data Reporting Guide
(EDRG), and Behavioral Health Supplemental Transactions that complies with the Behavioral Health Data System
(BHDS) Guide.
(2) Facility must provide claims and/or encounter codes to Beacon for reporting to the Washington State Health Care Authority
in accordance with the Rate Schedules in this Contract. Claims submitted for health care payments, also known as the
Fee for Service (FFS) payment type, must be submitted within current Washington State Health Care Authority timely
filing requirements or they will be denied for timely filing. Encounters submitted for health care reporting purposes, also
known as the Prepaid payment type, must be submitted to Beacon monthly by the 151h. Claims and encounter submissions
are used to reconcile services provided and directly impact future rate setting and/or funding available in the RSA. Failure
to submit claims and/or encounters for services rendered as outlined in your rate schedule(s) may result in future budget
reductions.
(3) Facility must collect and report to Beacon all applicable transactions described in the Department of Social and Health
Services (DSHS) most current Behavioral Health Data System (BHDS) Guide
(4) Unless there is an established SFTP site with Beacon, reports should be submitted to the following email address, which
is monitored multiple times each day: BeaconWAASO(ilbeaconhealthoptions.com.
a. The name of the report should be included in the email subject line.
(5) Facility will submit a completed monthly attestation regarding exclusionary checks to Beacon Health Options no later than
the 10th of each month.
(6) On a quarterly basis, on the last day of the month following the close of the quarter, Facility shall submit the DBHR
Capacity Management Form. The Capacity Management Form will identify PPW and IUID providers receiving SABG
funds, who are at (90) percent capacity, and what was or is being done to address capacity.
(7) For all SABG block grant funded service, Facility will provide all data required for state and federal reporting.
(8) Using the template provided by Beacon, the Facility shall submit a Monthly SABG Performance Report by the 10th of
each month
(9) Provide any additional reporting as detailed in the block grant plan
(10) Using the template provided by Beacon, the Facility shall submit an Annual SABG Performance Report 2 weeks prior to
HCA due date of each contract year detailing:
a. All performance outcomes met or unmet, including applicable supporting data
b. Barriers encountered and steps taken to remove barriers
c. Lessons learned with recommendations to improve upon future service outcomes
(11) Any other reports deemed necessary by Beacon to meet its reporting requirements pursuant to the terms of its agreement
with the Washington State Health Care Authority and deemed necessary by Beacon to meets its requirements to ensure
quality of care and services provided to Eligible Individuals.
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(12) For all CJTA funded services:
a. Facility will provide all data necessary to inform the development and monitor the implementation of any local
HCA approved CJTA plans.
b. Facility will submit a quarterly CJTA Quarterly Progress Report within twenty-five (25) calendar days of the state
fiscal quarter end using the reporting template provided by the HCA. CJTA Quarterly Progress Report must
include the following program elements:
i. Number of Individuals served under CJTA funding for that time period;
ii. Barriers to providing services to the criminal justice population;
iii. Strategies to overcome the identified barriers;
iv. Training and technical assistance needs;
v. Success stories or narratives from Individuals receiving CJTA services; and
vi. If a Therapeutic Court provides CJTA funded services: the number of admissions of Individuals into the
program who were either already on medications for opioid use disorder, referred to a prescriber of
medications for opioid use disorder, or were provided information regarding medications for opioid use
disorder.
(13) Failure to meet reporting requirements may result in a Corrective Action Plan (CAP).
VII. Documents Incorporated by Reference.
(1) Each of the documents listed below are incorporated by this reference into this Exhibit B-11 as though fully set forth herein,
including any amendments, modifications or supplements thereto. All services shall be provided in accordance with these
documents and legal authorities:
a. Beacon's contracts, program agreements, exhibits, amendments, and any other agreements with the
Washington State Health Care Authority;
b. The Medicaid State Plan and the 1915(b) Medicaid Waiver;
c. The Health Care Authority policies, the State Medicaid Manual (SMM) as applicable, the BARS Manual and any
applicable BARS Supplemental Instructions;
d. State laws and regulations including the Revised Code of Washington and the Washington Administrative Code;
e. Beacon External Policies and Procedures, including Beacon's Provider Handbook and Washington State ASO
Provider Handbook: Supplemental Appendix;
f. CPT Manual, HCPC Manual, and Washington State Service Encounter Reporting Instructions;
g. The Code of Federal Regulations Title 45 CFR and Title 42 CFR; and,
h. Title XIX of the Social Security Act.
VIII. Term & Termination.
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(1) In addition to and notwithstanding the provisions set forth in the Agreement, this Exhibit maybe suspended or terminated
by Beacon immediately upon written notice if:
a. Facility is disqualified, terminated, suspended, debarred, or otherwise excluded from or ineligible for participation
under the program or any other state or federal government-sponsored health program; or
b. The Agreement is terminated or not renewed.
IX. Confidential Information.
(1) Nothing contained in the Beacon Facility Agreement or associated exhibits shall be construed as prohibiting facility from
sharing information with the public as required by federal, state or local law.
X. Provider Communication.
(1) Nothing under this Agreement prohibits, or otherwise restricts, a healthcare professional acting within the lawful scope of
practice, from advising or advocating on behalf of an individual who is his or her patient, for the following:
a. The individual's health status, medical care, or treatment options, including any alternative treatment that may
be self-administered.
b. Any information the individual needs in order to decide among all relevant treatment options.
c. The risks, benefits, and consequences of treatment or non -treatment.
d. The individual's right to participate in decisions regarding his or her health care, including the right to refuse
treatment, and to express preferences about future treatment decisions.
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Addendum to Exhibit B-1 1.A8
Mobile Outreach Team Peer Support Specialist
This Addendum contains additional provisions applicable to administration of the Mobile Outreach Team Peer Support
Specialist under Exhibit B-11.
Objective:
Engage Peer Support Specialists to provide Mobile Outreach Services to identified clients in support of positive recovery
outcomes. Mobil Outreach Services will include peer support, support for education activities, resource referral, sharing their
lived experience with behavioral health issues and recovery principles.
Services:
1) Provide outreach to engage identified clients in services or referrals by listening, encouraging, coaching, empowering
and connecting with resources to enhance client recovery needs.
2) Work in conjunction with community partners, law enforcement, medical community, and other behavioral health
staff.
3) Provide peer support, support for education activities, resource referral, share lived experience with behavioral health
issues and recovery principles.
4) Services are provided countywide, where people are. Peer Support Specialist will go to homeless encampments,
food banks when open, the warming center when open, and the jail. They will travel with the Grant County Safe
Syringe program.
Reporting Requirements:
1) Facility shall follow the reporting requirements outlined in Exhibit B-11 for work performed under this Addendum.
2) In addition, Facility shall:
a) Report monthly data, by the 10 of the following month, regarding the unique number of individuals served,
number of services provided, and year to date number of unduplicated individuals served.
b) Provide a quarterly narrative by the 10 of the month following the end of the quarter describing the activities,
outcomes, barriers, and lessons learned.
3) Provision of required reports is a condition for payment from Beacon.
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Exhibit 8-20.A8
ESSB 5883 Start Up Funds
This exhibit contains the requirements for Facilities that received and expended ESSB 5883 Start Up Funds for crisis
stabilization and triage centers or the addition of residential beds.
I. General Provisions.
(1) Status updates on the implementation plan shall be submitted to Beacon no later than September 30, 2020 and monthly
thereafter until the facility is fully operational. The plan update must include:
a. Implementation timeline update
b. Any update or change in how the funding will be used for start-up costs
c. Any new barriers or challenges to implementation.
(2) The Facility shall begin submitting quarterly reports to Beacon, using the HCA's Crisis Triage/Stabilization and
Increasing Psychiatric Bed Capacity reporting template provided by Beacon, when the facility is operational. Reports
are due thirty days after the end of the FY quarter.
(3) The funding available maybe used for staffing, training, facility rental fees, furniture or required equipment, etc. Proviso
funds may not be used for capital costs, such as remodeling existing facilities or building new facilities.
(4) Payment will be made on invoice with clear detail that capital costs are not included in bill.
(5) Utilization of the funds is contingent on programs becoming operational by September 30, 2020.
(6) Once operational, Facilities that received ESSB 5883 Start Up Funds for either a Crisis Triage/Stabilization Center or to
increase psychiatric residential treatment beds for Individuals transitioning from psychiatric inpatient settings shall continue
submitting quarterly reports to Beacon using the HCA's Crisis Triage/Stabilization and Increasing Psychiatric Bed Capacity
reporting template provided by Beacon. Reports are due twenty (20) calendar days after the end of the state SFY quarter.
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Barbara Vasquez
From:
Linze Greenwalt
Sent:
Thursday, September 10, 2020 10:07 AM
To:
BOCC Consent
Subject:
FW: GrIS Amendment #8 zx
Attachments:
COG 301052 NCWA Amend 8 Eff 07-01-2020 (final).pdf
Good morning!
Fun fact, apparently the Beacon agreement that was signed a few weeks ago was not a final
agreement. I was not aware of that, so I apologize. Attached is the final agreement. It looks like they
also found more money for us, so we will definitely take that.
Thanks!
Linze
From: Black, Karen < Karen. Black@ beacon healthoptions.com>
Sent: Friday, August 28, 2020 4:33 PM
To: Veronica R. Perez <vrperez@grantcountywa.gov>; Linze Greenwalt <Igreenwalt@grantcountywa.gov>
Cc: Becknell, Leah <Leah.BeckneII@beaconhealthoptions.com>; Ferguson, Susan
<Susan.Ferguson@beaconhealthoptions.com>; Perez -Guerrero, Gerardo <Gerardo.Perez-
Guerrero@beaconhealthoptions.com>
Subject: RE: GrIS Amendment #8 zx
Hi Veronica and Linze,
Happy Friday! Attached please find a final pdf of your amendment for signature.
And, great news — an internal review found that an additional $20K in SABG funded needed to be added, increasing the
total budget from $1,024,499 to $1,044,499. Check the new totals for mobile outreach and SLID services. This kind of
news is always fund to share. O
Please return to me signed and I'll get if fully executed and back to you.
Have a great weekend,
Karen
Karen M. Black, MSIS
Contract Development Manager 11, Washington
Beacon Health Options
Cell: 253-313-8066
karen black(av)beaconhealthoptions.com
httDs://wa.beaconhealthoi)tions.com/
Upcoming time off: 918-9/9
LVED
1 211?!)
[RANT COUNTY COMMISSIONERS