HomeMy WebLinkAboutAgreements/Contracts - Sheriff & JailSTA
�{ State of Washington
f Department of Corrections
Contract No. K9412
Amendment No. 6
Th tis A\onn ein dlim en t is made by the Washington State Department of Corrections, hereinafter
referred to as "Department," and the Grant County, hereinafter referred to as "County" or "Contractor,"
for the purpose of amending the above -referenced Contract, heretofore entered into between the
Department and Contractor.
WHEREAS the purpose of this Amendment is to extend the term of the Agreement, increase the
per diem rate of compensation, and update other terms and conditions;
NOW THEREFORE, in consideration of the terms and conditions contained herein, or attached
and incorporated and made a part hereof, the Department and Contractor agree as follows:
ARTICLE I, DEFINITIONS is hereby replaced in its entirety with the following:
Section 1.1 Contractor — means Grant County and its employees, licensed
practitioners, contractors, vendors, and volunteers.
Section 1.2 Contractor inmate — means any resident of the Facility who is not a
Department offender.
Section 1.3 Department or DOC — means the Department of Corrections of the state
of Washington, any division, section, office, unit or other entity of the Department, or any
of the officers or other officials lawfully representing the Department.
Section 1.4 Department offender means any offender under the Department's
jurisdiction.
Section 1.5 DOC Utilization Management Office — means the Department's medical
contact that receives, reviews, and approves Contractor's non -Formulary and
extraordinary medical care requests to provide necessary medical care to Department
offenders. The Nurse Desk is available telephonically 24 hours a day, 7 days a week at 360-
725-8733 and during normal business hours via email at NurseDesk@DOC1.wa. gov.
Section 1.6 Extraordinary medical care — means medically necessary medical,
psychiatric or dental care that is not commonly available through the Facility's health
services and incurs additional cost. This may include, but not limited to, extraordinary
medications such as immunosuppressive drugs, and hepatitis C treatment and
antiretroviral medications.
Section 1.7 Facift — means the Contractor's non -Department operated correctional
facility used for the total confinement of Department offenders and Contractor inmates.
State of 'Washington K9412(6) Page 1 of 9
Department of Corrections 208362
Section 1.8 Formulary — Medications in this category may be prescribed when
medically necessary according to the Offender Health Plan (OPH) and require no further
approval for use. The DOC Pharmaceutical Management and Formulary Manual can be
viewed at: http://doc.wa.gov/business/healthcareproviders/default.asp
Section 1.9 In-Facili , care — means medical, mental health and dental care provided
as part of the per diem to include all over-the-counter medication, which is any medication
that does not require a prescription, and routine medical supplies, routine
medical/psychiatric/dental care, regular health screenings, and emergent medical
treatment provided on-site at the Facility that is undistinguishable from services provided
to Contractor inmates.
Section 1.10 Licensed practitioner - means any licensed health care practitioner
performing services within the person's authorized scope of practice following RCW Title
18.
Section 1.11 Medicaid — means Title XIX of the Social Security Act enacted by the social
security amendments of 1965 (42 U.S.C. Sec. 1396; 79 Stat. 343), as amended.
Section 1.12 Medically necessary care — means medical care that meets one or more of
the following criteria for a given patient at a given time:
Section 1.12.1 Is essential to life or preservation of limb, OR.
Section 1.12.2 Reduces intractable pain, OR
Section 1.12.3 Prevents significant deterioration of activities of daily living
(ADCs), OR
Section 1.12.4 Is of proven value to significantly reduce the risk of one of the
three outcomes above (e.g. certain immunizations), OR
Section 1.12.5 Immediate intervention is not medically necessary, but delay of
care would make future care or intervention for intractable pain or preservation
of ADLs significantly more dangerous, complicated, or significantly less likely to
succeed, OR
Section 1.12.6 Reduces severe psychiatric symptoms to a degree that permits
engagement in programming that advances correctional interests, OR
Section 1.12.7 Is described as part of a Departmental policy or health care
protocol or guideline and delivered according to such policy, protocol, or
guideline, OR
Section 1.12.8 From a public health perspective, is necessary for the health and
safety of a community of individuals and is medically appropriate, but may not be
medically necessary for the individual (for example, treatment for head lice);
State of Washington K9412(6) Page 2 of 9
Department of Corrections 208362
Section 1.12.9 Not considered experimental or to be lacking in medically
recognized professional documentation of efficacy; and,
Section 1.12.10 Not administered solely for the convenience of the offender or the
health care provider.
Section 1.13 Offender day — means any day a Department offender is in the custody of
the Contractor including the first day the offender is sanctioned or held by the Department
to a term of confinement to be served in the Facility.
Section 1.13.1 An offender day ends at midnight of the day immediately
preceding the day of the offender's release from the Department's sanction,
transferred to a Department institution, transferred to another Facility, released to
the custody of the Department, or released to the community.
Section 1.13.2 An offender day shall not include any day that is by state law the
financial responsibility of the Contractor or any other jurisdiction.
Section 1.14 Offender Health Pian — means the Department's Offender Health Plan
(OHP) that describes the medically necessary medical, mental health, and dental services
available to Department offenders, as well as the services that are limited or not available.
The OHP is not a contract or a guarantee of services to Department offenders.
Section 1.15 Per diem rate — means the amount per day per Department offender that
the Contractor will be reimbursed by the Department for all in -Facility care, including but
not limited to all medical, mental health, dental, food, clothing and housing which are the
same or similar that is provided to Contractor inmates.
Section 1.16 Secretary - means the Secretary of the Department and delegates
authorized in writing to act on the Secretary's behalf.
ARTICLE II, SECTION 2.1 TERM is hereby amended, in part, as follows:
Section 2.1 Term. This Agreement supersedes all previous oral and written contracts
and agreements between the parties relating to the confinement, care, and treatment of
Department offenders. This Contract commences on January 1, 2016 and continues
through ((n^^^mom^� �1, 220..-0))) December 31, 2021, unless terminated by either party
pursuant to this Contract.
ARTICLE II, SECTION 2.4 PER DIEM BILLING is hereby amended, in part, as follows:
Section 2.4 Per Diene. Billing. The per diem rate is $76.49 per Department offender,
for January 1, 2019 through December 31, 2019. The per diem rate is $78.79 per Department
offender for January 1, 2020 through December 31, 2020. Eegi ]n&. -January 1, 2021
through December 31, 2021, the per diem rate is $82.73 per Department offender. The
Contractor agrees to only bill the Department monthly for the actual bed days used by
Department offenders in the preceding month. The Contractor also agrees that it will not
bill the Department for any bed day that is the financial responsibility of any other
State of Washington K9412(6) Page 3 of 9
Department of Corrections 208362
jurisdiction, and that it will submit monthly itemized bills to the Department in an
electronic spreadsheet format that includes the offender's name, DOC number, date of
birth, and dates the offender was held by the Contractor under the Department's authority.
If applicable, the Contractor agrees to identify in the monthly bill, any beds that are being
counted toward the day -for -day exchange for any Contractor boarder being held by the
Department in a Department institution.
ARTICLE III, SECTION 3.5 RETURN OF DEPARTMENT OFFENDER TO THE COMMUNITY
is hereby replaced in its entirety with the following:
Section 3.5 Return of Department Offender to the Communit
,L. The Contractor
agrees to complete a national "Wants and Warrants" check and to notify the Department
and any interested jurisdiction of the Department offender's pending release. The
notification shall occur at least seven business days and not later than 24 hours prior to a
Department offender's release to the community due to the Department offender's
completion of a sanction or sentence. The Department offender may be released directly
from the Facility when the Department takes custody of the offender, when the
Department's sanction has been served, or when the Department's hold or detainer is no
longer valid, whichever is earliest.
ARTICLE III, SECTION 3.6 JURISDICTION is hereby replaced in its entirety with the following:
Section 3.6 Jurisdiction. Department offenders placed in the Contractor's custody are
under the Department's jurisdiction, however upon the Department offender's placement
at the Facility, the Department authorizes the Contractor to assume custody. The
Department agrees to provide the Contractor with documentation of the Contractor's
authority to detain the offender. The Contractor agrees to immediately notify the
Department of all non -Department holds if and when non -Department holds are placed
on Department offenders or when non -Department holds are closed or removed from
Department offenders as detailed in Attachment A.
Section 3.6.1 The Contractor agrees to not transfer or transport any Department
offender held by the Department or serving a Department sanction for a term of
confinement until the Department takes custody of the offender, the Department's
sanction has been served, or the Department's hold or detainer is no longer valid.,
whichever is earliest.
Section 3.6.2 Department offenders detained in the Facility shall only be
transferred to another confinement facility or Department institution after
authorization is obtained from the Violator Desk, the after -business Duty Officer,
or the Contract Coordinator as detailed in Attachment A.
ARTICLE III, SECTION 3.8 MEDICAL CARE is hereby replaced in its entirety with the following:
Section 3.8 Medical Care. It is the intent of the parties that Department offenders in
the Contractors custody receive safe, appropriate and cost-effective medical care
consistent with the Department's Offender Health Plan and Attachment B.
State of Washington K9412(6) Page 4 of 9
Department of Corrections 208362
Section 3.8.1 Contractor Responsibilities.
3.8.1.1 The Contractor agrees to provide Department offenders in the
Facility care identical to the care provided to Contractor inmates. The
Contractor agrees to provide Department offenders twenty-four (24) hour
access to emergency medical care. The Contractor agrees to provide the
most cost-effective,, medically appropriate method of transportation and
security for all Department offenders taken out of the Facility, to in -county
emergent and non -emergent medical appointments. The.Contractor may
require Department Offenders to pay co -pay fees for medications.
3.8.1.2 The Contractor agrees to follow the Department's pre-
authorization procedure through the Departments Utilization
Management Office for all extraordinary medically necessary care
provided to Department offenders beyond what is normally provided to
Contractor's inmates.
3.8.1.3 ONLY the Department's Nurse Desk can authorize the transfer
of a Department offender from the Facility for medical reasons.
3.8.1.4 In an emergency, when pre -authorization is not feasible, the
Contractor agrees to notify the Department, as soon as possible, but not
later than four hours after transporting a Department offender to the
nearest emergency room or other medical facility and before any hospital
admission.
3.8.1.5 Following the OHP and consistent with RCW 70.48.130(2), the
Department does not consider experimental or elective procedures to be
medically necessary. The Department will not reimburse for elective or
experimental medical procedures. The Department will not be responsible
for the payment of or for medical care required as a result of any tort
committed by the Contractor., or its employees, or by its agents,,
contractors,, vendors, or volunteers in the course of their providing
services to Department offenders, or for care which could have
foreseeably been prevented.
3.8.1.6 The Contractor agrees to be financially responsible for all
unauthorized health care provided to Department offenders.
3.8.1.7 The Contractor agrees to be financially responsible for any
medical costs incurred due to the negligent action or inaction of
Contractor -'s employees.
Section 3.8.2 Department Responsibilities.
3.8.2.1 The Department agrees to be financially responsible for pre -
authorized extraordinary medical care provided by the Contractor to
State of Washington K9412(6) Page 5 of 9
Department of Corrections 208362
Department offenders that is consistent with this Contract, the OHP and
the Department's prescription formulary.
3.8.2.2 If the Department offender is under the exclusive jurisdiction of
the Department, then the Department may authorize medically necessary
care. However, if it is later determined that another jurisdiction(s) or entity
is financially responsible; then the Department may not pay for part or all
of the costs associated with the medically necessary care.
3.8.2.3 The Department agrees to reimburse the Contractor for
emergency medical costs incurred by a Department offender under the
conditions of this Contract. Emergency medical care costs may include a
facility fee, physician services, labs and x-rays. The Department is not
obligated to reimburse the Contractor for medical care or treatment
provided to a Department offender without the Department's pre-
authorization in non -emergency situations, or without the required
notification as specified by paragraph 3.8.1.4 in emergency situations.
3.8.2.4 The Department may, at its option, request the return of a
Department offender for medical reasons. The Department's medical
financial responsibilities under this Contract terminate when the
Department takes custody of the offender, when the Department's
sanction has been served, or when the Department's hold or detainer is
no longer valid, whichever is earliest.
3.8.2.5 The Department at its sole discretion may provide Department
offenders prescription medications or, reimburse the Contractor for
prescription medications it provides as long as the Contractor provided
prescription medications are consistent with the Offender Health Plan and
the FormulaLy. Consistent with the medication continuation practice at
DOC Reception Centers, DOC Contracted Violator Facilities are
authorized to receive reimbursement for Non -formulary or Restricted
Formulary prescriptions for up to thirty (30) days for general medical
medications and sixty (60) days for mental health medications provided
to patients returning to custody due to a violation. However, the
Department still encourages Contracted Violator Facilities to use
Formulary medications whoever possible. Over-the-counter (OTC)
medications and/or medical supplies are not reimbursable items.
For any single prescription that is expected to exceed $2500.00 per
month, notification to the Department's Utilization Management Office
(Nurse Desk) is required. Any questions related to medication
reimbursement may be directed to the Nurse Desk. See Attachment B.
Section 3.8.3 Safe Transfer of Care.
3.8.3.1 HIPAA — Both parties agree to follow the Health Insurance
Portability and Accountability Act of 1996 (HIPAA). HIPPA protects the
State of Washington K9412(6) Page 6 of 9
Department of Corrections 208362
privacy of individually identifiable protected health information. It
allows the exchange of this information between the Department and the
Contractor for the purpose of billing and payment. This allows the
Contractor to provide the Department documentation of the Department
offender's health information and Contractor's treatment activities so that
the Contractor can receive reimbursement under this Contract for costs of
health care provided to Department offenders. See CFR 45 § 164.506.
HIPPA also clarifies the standard for use and disclosure for correctional
institutions and other law enforcement custodial situations in CFR 45
§164.512.
3.8.3.2 The Contractor agrees to consult with the Department's
Utilization Management Office prior to transferring a Department
offender for medical reasons. "Transferring," as used in this section,
includes moving the Department offender into the Contractor's medical
unit within the Facility.
3.8.3.3 The Contractor also agrees to consult telephonically with the
medical staff at any facility receiving the Department offender and agrees
to transport, with the Department offender, any applicable medical
records, current care instructions, and all appropriately labeled
medications. The medical record shall at a minimum include the
Department offender's name, DOC number, date of birth, any known
allergies, current medication list, and description of current medical
problem(s), the Facility medical care previously provided, and the Facility
medical staff contact information.
3.8.3.4 Prior to the Contractor transferring a Department offender -to any
other correctional facility, the Contractor agrees to obtain the
Department's authorization, and if approved -to provide a copy of the
Department's authorization to hold the Department offender at the
receiving facility.
3.8.3.5 The Department agrees to transport, with the Department
offender, any applicable medical records, current care instructions, and all
appropriately labeled medications. The medical record shall at a
minimum include the Department offender's name, DOC number, date of
birth, any known allergies, current medication list and description of
current medical problem(s), the Facility medical care previously provided,
and the Departments institutional medical staff contact information.
Section 3.8.4 Medical Care Utilization Review. The Contractor agrees to allow
the Department and its agents to conduct concurrent and retrospective utilization
audits and reviews of any and all medical services provided to Department
offenders. The Contractor agrees that any and all of its medical service contracts
will include authorization for the Department's concurrent and retrospective
utilization audits and reviews of any and all medical services provided to
Department offenders.
State of Washington K9412(6) Page 7 of 9
Department of Corrections 208362
Section 3.8.5 Medical Bi11in . Contractor costs incurred for a Department
offender's medical care not included in the per them may be reimbursed by the
Department consistent with this Contract and Attachment C.
The Contractor agrees to electronically send itemized monthly bills to the
Department at: DOCHQMedicalRAB@DOC1.WA.GOV.
The itemized reimbursement claims must contain the Department offender's name
and DOC number and attached supporting documentation of the service provided
that includes the date(s) of service, the name of the practitioner who ordered the
service, details of the service/item(s) provided, the prescriptions(s) provided, the
facility(s) that provided the service(s), and a copy of any health care claims paid
to off-site providers. All reimbursements claims must also include documentation
showing proof of payment by the Contractor.
The Contractor agrees to submit itemized billing statements electronically to the
Department for reimbursement and data collection purposes. If billings received
do not contain the detailed information or supporting documents required, they
will be returned to the Contractor and not processed.
The Contractor agrees to submit itemized bills for medical services not later than,
six months after the date of service. If medical or pharmaceutical bills are
received 365 days or more after the date of service, the Department may decline
to reimburse the Contractor for those bills.
ARTICLE III, SECTION 3.9 NOTIFICATION OF RELEASE DATE is hereby replaced in its
entirety with the following:
Section 3.9 Notification of Release Date. The Department agrees to calculate a
Department offenders release date and to notify the Contractor, in writing, of the
Department offender's release date. The Contractor will not release a Department offender
unless the Department's sanction has been served, or when the Department's hold or
detainer is no longer valid, whichever is earliest.
The Contractor also agrees to notify the Department if a Department offender receives
additional confinement or holds from anon -Department jurisdiction(s). The Department
will not be financially responsible for any per them or medical costs beyond the sanction
time imposed by DOC.
ATTACHMENT A, DOC CONTACT INFORMATION is hereby replaced in its entirety by
ATTACHMENT A-1, DOC CONTACT INFORMATION, which is attached hereto and
incorporated by reference herein.
ATTACHMENT B. PREAUTHORIZATION AND MEDICAL BILLING INSTRUCTIONS is
hereby replaced in its entirety by ATTACHMENT B-1, PREAUTHORIZATION AND MEDICAL
BILLING INSTRUCTIONS, which is attached hereto and incorporated by reference herein.
State of Washington K9412(6) Page 8 of 9
Department of Corrections 208362
Additions to this text are shown by underline and deletions by (,1giXi 14P C) -':j +
skikeeat)). All other terms and conditions
remain in full force and effect. The effective date of this Amendment is January 1,, 2021.
THIS AMENDMENT, consisting of nine (9) page(s) and two (2) attachments is executed by the persons
signing below who warrant that they have the authority to execute this Amendment.
GRANT COUNTY SHERIFF'S OFFICE
2JTom Jone Date
BOARD OF COMMISSIONERS
;Ow TY, WASHINGTON
Cisy--cator, BOO O Chair Date
Danny vStone, Vice -Chair Date
2
Date
Rob Jones, Member
ATTEST -,,-2
Barbara Vasqz date
Clerk of the Bird
WASHINGTON STATE DEPARTMENT OF
CORRECTIONS
EisenDebra J`Digitally signed by Eisen,
, .
-, Debra J. (DOC)
(DOC) 'Date: 2020.12.31 12:43:01
-08'00'
Debra Eisen, Contracts Administrator
Approved as to Form: This Amendment format was approved by the office of the Attorney General.
Approval on file.
Date
State of Washington K9412(6) Page 9 of 9
Department of Corrections 208362
DOC Contact Information
Violator Medical Issues
• Pre -Authorization for
extraordinary medical expenses
• Pre -Authorization for high cost
medications.
• Notification: of emergent
offender medical issue or
• Hospitalization
• Requests for transfer due to
medical or mental health issues.
Violator Issues
• To request a transfer of violator
• Notification of additional non -
DOC sentence/sanction
confinement
• Notification of violator
discipline/new charges
• Notification of any non- DOC
detainers/ holds
DOC Secretary Warrant
Concerns after normal business hours
For example: offenders under DOC
supervision or issues related to DOC
staff or DOC equipment
Violator Medical Billing
0 Requests for reimbursement for
medical care not included in the
offender base rate.
DOC Contract Coordinator
• Contract concerns/issues
• Death of a Violator
• Violator Escape
Last updated 1/11/2017
ATTACHMENT A-1
DOC Nurse Desk -24/7
0 360-725-8733
Additional contact during business hours:
• NurseDesk@docl.wa.gov
• Fax: 360-586-9060
DOC Violator Desk
Monday -Friday (except Holidays): 7:00 am -5:00 pm
• 1-855-584-6528
• Violatordesk@doc.wg.gov
• When calling outside of hours listed call the DOC
Warrants Desk and ask to speak to the CCD Section
Duty Offlcer.
DOC Warrants Desk -24/7
0 360-725-8888
DOC Warrants Desk -24/7
Warrants Desk will refer to the appropriate Duhj Officer
0 360-725-8888
Medical Disbursement Unit
0 DOCHQMedicalRAB@docl.w
0 360-725-8298
0 Fax: 360-586-1320
Greg Oliver
Monday -Friday (except Holidays): 8:00 am -5:00 pm
• Work 360-725-8943
0 After hours/holidays 360-584-3202
0 ore�ory.oliver@doc.wa.gov
State of Washington K9412(6) Page I of I
Department of Corrections Attachment A-1
ATTACHMENT B-1
PRE -AUTHORIZATION AND MEDICAL BILLING INSTRUCTIONS
Definitions
Per Diem Rate - the cost per day per Department offender for all care, included in facility medical costs
housing which is the same or similar care provided to County/City inmates.
DOC Utilization Management Office (Nurse Desks - the Department's medical contact that receives,
reviews and approves extraordinary medical expenses and non -formulary requests for DOC Offenders.
The Nurse Desk is available 24 hours a day via phones at (360) 725-8733 or during normal business hours
via email at NurseDesk@docl.wa.gov
Extraordinary Medical Care - medically necessary care that is not commonly available through the facility
health services and incurs additional cost. Examples of extraordinary medical care may include, but are
not limited to, specialty consults, emergency room care, hospital care, ancillary charges and ambulance
services.
Extraordinary Medical Expense - medical expenses that are beyond the medical expenses included in the
Base Rate per Diem for in -facility care for Department offenders including high cost/specialty medication
for chronic conditions.
In -Facilites Care - medical care provided to Department offenders as part of the Base Rate per Diem to
include over-the-counter medications, routine medical, mental health and dental care, regular medical
screenings and emergent medical treatment, identical to services provided to other County inmates.
Formulary Medications - medications described in the DOC Pharmaceutical Management and Formulary
Manual. Medications in this category are described as medically necessary and require no further approval
for use provided the criteria listed in the formulary are met. The formulary, is available online at the
following link: h. tip: www.doc.wa goy/corre, ctions services dock/for nulary. di.
Medically Necessary Care - medical care that meets one or more of the following criteria for a given patient
at a given time:
• Is essential to life or preservation of limb, or
• Reduces intractable pain, or
• Prevents significant deterioration of activities of daily living (ADLs), or
• Is of proven value to significantly reduce the risk of one of the three outcomes above (e.g.
certain immunizations), or
• Immediate intervention is not medically necessary, but delay of care would make future
care or intervention for intractable pain or preservation of ADLs significantly more
dangerous, complicated, or significantly less likely to succeed, or
• Reduces severe psychiatric symptoms to a degree that permits engagement in
programming that advances correctional interests, or
• Is described as part of a Departmental policy or health care protocol or guideline and
delivered according to such policy, protocol or guideline, or
State of Washington K9412(6) Page 1 of 5
Department of Corrections Attachment B-1
• From a public health perspective, is necessary for the health and safety of a community of
individuals and is medically appropriate, but may not be medically necessary for the
individual (for example, treatment of head lice)
Any medically necessary care provided shall NOT:
• Be considered experimental or to be lacking in medically recognized professional
documentation of efficacy, or
0 Be administered solely for the convenience of the offender or the health care provider
Non Formulary — medications in this category are not generally prescribed in DOC. They are not medically
necessary usually for one of the following reasons:
• Experimental medications or experimental use of medication
• Medications for which alternative therapeutic modalities may already exist on the
formulary list
• Medications for which alternative therapeutic modalities may already exist on the over -
the counter (OTC) store list
• Medications with the sole purpose of treating conditions recognized in the Offender
Health Plan (OHP) as not medically necessary
• Brand-name medication when a generic product is available within the therapeutic class
Offender Health Plan ( — The Department's OHP describes medically necessary medical care, mental
health and dental care services that are available to Department offenders, as well as the services that are
limited or not available. The OHP is not a contract or a guarantee of payment for services provided to
Department offenders. The Offender Health Plan (OHP) is available online at the following link:
htt-D://doc.-wa.gov correc-Lions/services/health.htm .
Restricted Formulary — medications in this category are described as medically necessary but restricted to
documented failure of a Formulary medication(s) or certain populations or disease states. Refer to the
Medication Formulary status for specific criteria.
%VII
Pre -Authorization
The County/Violator Facility must obtain pre -authorization through the Departments Utilization
Management Office for all health care beyond what is normally provided to County inmates. This includes
notification of incarceration of offenders who are on specialty/high cost medications for long-term or
chronic conditions such as Hepatitis C, HIV, MS or any other condition that requires the consistent
administration of medications during their incarceration.
In the case of an emergency when pre -authorization is not feasible, the County/Violator Facility must notify
the Department's Utilization Management Office as soon as possible, but no later than four (4) hours after
transporting the Department offender to an emergency room or other medical facility and before any
hospital admission.
The following information must be included with notifications:
0 The date and time the offender left your facility for the medical event;
0 The name of the hospital or medical facility;
9 The medical issue/reason for trip; and
State of Washington K9412(6) Page 2 of 5
Department of Corrections Attachment B-1
0 The date and time the offender returned to your facility (if applicable)
Please note that if ANY hospitalization results in an inpatient event the Department, if properly notified,
will apply for Medicaid coverage under the Affordable Care Act and the County/Violator Facility will not
be billed for qualifying services. However, the County/Violator Facility must notify the Department of the
hospitalization and follow the emergency notification and/or pre -authorization process so that a Medicaid
application can be initiated for the event.
The Department is not obligated to reimburse the County/Violator Facility for medical care or treatment
provided to a Department Offender without the Department's pre -authorization or notification within the
timeframe specified in the contract.
Pre -authorization requests for extraordinary medical care including pertinent medical records and other
supporting documentation are faxed to the Utilization Management Office at (360) 586-9060.
The Department's Utilization Management Office will be available via telephone to assist staff 24 hours a
day and 7 days per week.
From 8 a.m. - 4:30 p.m. Monday — Friday (except holidays), the Nurse Desk is available at
NurseDesk@docl.wL.gov or (360) 725-8733.
After normal business hours and during holidays, please call (360) 725-8733. The call will forward
to the on-call UM Nurse.
If authorization for extraordinary medical care is denied, the practitioner may appeal the Department's
decision by submitting a written request and supporting documentation to DOC via email at
DOCHOMedicalRAB@DOC1.wa..gov
Pharmaceuticals and Non -Formulary Requests
Consistent with the medication continuation practice at DOC Reception Centers, DOC Contracted Violator
Facilities are authorized to receive reimbursement for Non -formulary or, Restricted Formulary
prescriptions for up to thirty (30) days for general medical medications and sixty (60) days for mental health
medications provided to patients returning to custody due to a violation. However, the Department still
encourages Contracted Violator Facilities to use Formulary medications whenever possible. Over-the-
counter (OTC) medications and/or medical supplies are not reimbursable items.
For any single prescription that is expected to exceed $2500.00 per month, notification to the Department's
Utilization Management Office (Nurse Desk), is required.
Any questions related to medication reimbursement may be directed to the Nurse Desk at
NurseDeskWocl.wa.grov or (360) 725-8733.
Medical Billing
It is the responsibility of the billing County/Violator Facility to process payment for all bills prior to sending
them to the Department for reimbursement. However, if the County/Violator facility is unable to make
payment for direct billings, you may send a written request to the Department to process payment on the
behalf of the County/ Violator Facility can be submitted by fax (360) 586-1320 or email to
DOCH0MedicalRAB@DOC1.WA.WV. Please include a copy of the bill with the request. The Department
will respond to written requests for assistance with payment of direct billings within seven (7) business
* 00
days of receipt. Please do not instruct the billing entity to bill the Department directly.
State of Washington K9412(6) Page 3 of 5
Department of Corrections Attachment B-1
Monthly medical billings are to be submitted electronically to the Medical Disbursement Unit at
DOCHOMedicalRAB@DOCI.WA.GOV. Itemized invoices for services provided onsite by the
incarcerating facility should be submitted to the Department on a monthly basis for the previous month's
services. Any billing for offsite services should be submitted for reimbursement or payment within thirty
(30) days of the date of service. We understand that each monthly billing may have medical invoices for
previous months and that is acceptable; however, in an effort to ensure the cleanest billing process, please
bill one month at a time whenever possible. Itemized statements must be submitted in the format below
with supporting documentation when applicable. Incomplete or missing data or supporting
documentation may result in delays or denial of payment.
If unable to submit billing electronically, please fax to:
Department of Corrections
Health Services Contract, Claims and Benefits Unit
Fax: (360) 586-1320
A sample billing entry is provided below
" fl _> x ,.r. .�"� a 1. �}�''� ■:■^1I.\ /I: '�./.�.i r-' 4 F .�Iv
Warne. °�tame.r��r�naa�e: Yuen siren �r� v. << �uan��
Doe John 999999' 8127112 lGabapentin 30 MG TAB 14� N i N {N 25.00
'Jackson , Jose
h 1111111 811112 'Clonidine 1 MG TAB 6 N IN r N 34.00
' !8/14/12 tProvidence St Peer Hospital Y iSmith Joe 888888; t, .... _ . ..: a _ K J.
a N "Broken Leg 21500.00
Monthly billings must include:
• A coversheet with all pertinent details including the total amount billed, month of service, facility
name, contact information for the billing staff( including an email address, phone number and fax
number), address for where to submit the payment, an invoice number (this is your internal invoice
tracking number) and Federal Tax ID number;
Itemized Charges to include the name of the offender and DOC# who the charges are for, what the
charges are for and the total amount of the charges. If you are asking for reimbursement for
services paid to offsite providers, a copy of the original healthcare claim form paid by the facility
must be included. If charges are for onsite services, the detail of what services were provided must
be listed along with copies of any paid bills for those services with a break-out of the amount
attributed to the DOC offenders.
Supporting_ documentation including verification of DOC hold, any authorizations from the
Utilization Management Office and all Health Insurance Claim Forms (CMS 1500 or UB -04) and/or
invoices from community providers showing what was billed and documentation of what you
paid if requesting reimbursement, for medications, you must provide a copy of the pharmacy bill
to include the drug name, dosage and quantity provided and amount paid for the drugs;
• Credits for returned prescriptions (if applicable) listed in the same way as noted above and clearly
marked as CREDIT.
State of Washington K9412(6) Page 4 of 5
Department of Corrections Attachment B-1
Once DOC has completed the verification process and is ready to process payment, the County will be
notified by email or fax of any denials or credits.
For billing questions or concerns, please email DOCHOMedicalRAB@DOCI.WA.GOV
HIPAA
The Health Insurance Portability and Accountability Act (HIPAA — CFR 45) of 1996 protects the privacy of
individually identifiable, protected health information or PHI. This law allows for the exchange of this
information between covered entities for the purpose of billing and payment which allows you to provide
the required back-up documentation regarding the offenders' health information and treatment activities
for support of payment purposes (§ 164.506 (c)(3)). It further clarifies the standard for use and disclosure
for correctional institutions and other law enforcement custodial situations in §164.512(k).
State of Washington K9412(6) Page 5 of 5
Department of Corrections Attachment B-1