HomeMy WebLinkAboutAgreements/Contracts - Sheriff & JailINTERAGENCY CONTRACT
PURPOSE
On December 17 2020 Governor Inslee issued Proclamation 20-80, DOC — Prison
Commitments. The proclamation temporarily suspends the transfer of newly sentenced felons from
county jails to Department of Corrections' facilities. This Contract is entered into by County
(hereinafter Contractor or County) and the Department of Corrections (hereinafter Department or
DOC) to establish a temporary per diem rate effective during this temporary suspension and
Contract term. This Contract is entered into in accordance with the provisions of RCW 39.34 and
RCW 70.48.240.
In consideration of the promises, payments, covenants and agreements contained in this Contract,
the parties agree as follows:
Article I DEFINITIONS
Section 1.1 Contractor — means the County of Washington State named in the signature block
of this Contract and its employees, licensed practitioners, contractors, vendors, and volunteers.
Section 1.2 Contractor inmate - means any resident of the Facility who is not under the
jurisdiction of the Department.
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 an individual housed at a County facility pending
transfer to a state prison reception center. This includes court sentenced felons, DOC sanctioned
individuals for a prison DOSA return, or community custody prison returns.
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(wDOCI.wa.gov.
Section 1.6 Extraordinary medical care - means medically necessary psychiatric or dental care
that is not commonly available through the Facility's health services and incurs additional cost.
Section 1.7 Facility - means the Contractor's non -Department operated correctional facility
used for the total confinement of Department Sentenced Felons and Contractor inmates.
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Section 1.8 Formulary — Medications in this category may be prescribed when medically
necessary according to the Health Plan (OPH) and require no further approval for use. The DOC
Pharmaceutical Management and Formulary Manual can be viewed at:
littp://doc.wa.gov/business/healtlicarel2roviders/def,iult.asi2
Section 1.9 In -Facility 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 in accordance with 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 (ADLs), 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);
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 Sentenced Felon or the
health care provider.
Section 1.13 Offender day - means any day, including the first day that a Sentenced Felon is in
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custody in the Contractor's Facility.
Section 1.13.1 An Offender day ends at midnight of the day immediately preceding the
day of the Sentenced Felon's transfer to a DOC reception center.
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 Per diem rate - means the amount per day that the Department will reimburse the
Contractor for housing each Sentenced Felon. Housing includes all in -Facility care, including but
not limited to, all over the counter medications, medical supplies, medical, mental health, dental,
food, and clothing, that are the same or similar than that provided to Contractor inmates.
Section 1.15 Secretary - means the Secretary of the Department and delegates authorized in
writing to act on the Secretary's behalf.
Section 1.16 Sentenced Felon - means an individual sentenced by a court of law to state prison,
under DOC jurisdiction for sentences of more than 365 days and individuals sanctioned to return
to confinement. Sentenced Felons are temporarily detained in County jail until transfer to a state
reception center by DOC can be arranged.
Section 1.17 Washington DOC Health Plan - means the Department's Health Plan (HP) 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 HP is not a
contract or a guarantee of services to DOC Sentenced Felons.
Article II CONTRACT TERM/PAYMENT
Section 2.1 Contract Term. This Contract commences on December 21, 2020, and
continues through January 8, 2021. This Contract may be extended by means of a written
agreement that is signed by an authorized representative of each party to the Contract. This
Contract supersedes all previous oral and written contracts and agreements between the parties
relating to the confinement, care, and treatment of Department Sentenced Felons.
Section 2.2 Termination Due to Non -Appropriation of Funds. The terms of this
Contract are contingent upon sufficient appropriations by the Washington State Legislature to the
Department to pay sums pursuant to this Contract. If the Legislature does not allocate sufficient
appropriations, this Contract shall terminate immediately without penalty and without the notice
period. The Department is financially responsible for payments to the County for the services
provided to Sentenced Felons prior to contract termination.
Section 2.3 Sillin .
Section 2.3.1 Per Diem:
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Department of Corrections
a. For Prison DOSA and CCP returns, the Contractor will be paid the
current negotiated violator rate through the 7th day of confinement.
Beginning on the 8th day, the Contractor will be paid $93.71, the
contracted per diem rate under this Contract.
b. Beginning on the 81h day, the Department will pay Contractor the per
diem rate of ninety-three dollars and seventy-one cents ($93.71) for
DOC Sentenced Felons who are not Prison DOSA or CCP returns.
Section 2.3.2 The Contractor will not bill the DOC, and DOC will not pay, for any bed day
that is the financial responsibility of any other jurisdiction, for example, days
1— 7, beginning on the date of court sentencing, of the Sentenced Felon's stay
at the County facility. (See RCW 70.48.410)
Section 2.3.3 The Contractor will only bill the DOC for bed days that were used by DOC
Sentenced Felons during the Contract term and billable per RCW 70.48.410.
Section 2.3.4 The Contractor will submit itemized bills to the Department electronically
using Attachment D for per diem reimbursement.
Section 2.3.5 Medical Billing. With required documentation, (See Attachment B) the
Department will Reimburse Contractor for the following medical services
when provided to DOC Sentenced Felons on or after the 81h day at
Contractor's facility:
a. Off-site Medical Costs, to include physician visits and hospital
emergency services, for care provided to specific DOC Sentenced Felons,
only when the Contractor furnishes the documentation required. (See
Attachment B, Pre -Authorization and Medical Billing Instructions and
Attachment C, Sample Medical Billing Reimbursement Form)
b. Transport to Hospital, reimbursement only when documentation of
transport to hospital for emergency medical services is provided.
Article III RESPONSIBILITIES
Section 3.1 Target Population. The target populations under this Contract are Sentenced
Felons, DOC sanctioned individuals for a prison DOSA return, or community custody prison
returns.
Section 3.2 Housing. The Contractor will take members of the Target Population into
custody pursuant to this Contract. Such individuals may be integrated with the Contractor's
inmate population, as allowed by law, regulation, and ordinance.
Section 3.3 Transportation to DOC Reception Center
Section 3.3.1 Due to a state-wide surge in Covid-19 infections and pursuant to
Proclamation 20-80, DOC Prison Commitments, the Department is
suspending its regularly scheduled transfer of Sentenced Felons, from the
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Department of Corrections
County to a DOC reception center, for one (1) week only, December 21
through 25, 2020. The Department will return to its regular every -other -week
pick-up schedule on January 4, 2021. When DOC transfers resume, the
County's pick-up day will be the same day of the week that it was before the
one-week suspension, unless, during the week of January 4 through 8, 2021,
the increased numbers of Sentenced Felons to be transferred necessitates
scheduling an additional transfer from that facility. If an additional transfer
is needed then the parties will mutually agree to a transfer time later that day
or on another day later that same week.
Section 3.3.2 Contractor will not send DOC Sentenced Felons from its facility to any other
County jail nor receive DOC Sentenced Felons from another County jail into
its own facility during the term of this Contract.
Section 3.3.3 Contractor will provide the Department's two reception centers, Washington
Corrections Center and Washington Corrections Center for Women, with
advance lists of their incoming admissions by the close of business on
December 23, 2020 and December 30, 2020.
Section 3.4 Public Records. Both parties agree to comply with Washington State's Public
Records Act, RCW 42.56.040 through 42.56.570 (Act). The Act requires each party to make available
for inspection and copying nonexempt "public records." A "public record" includes any "writing
containing information relating to the conduct of government or the performance of any
governmental or proprietary function prepared, owned, used, or retained" by the party in accord
with RCW 42.56.070(1).
Section 3.5 Medical Care. It is the intent of the parties that Sentenced Felons in the
Contractor's facility receive safe, appropriate and cost-effective medical care consistent with the
care provided to Contractor inmates in the facility. Please see the Department's Health Plan. and
Attachment B, Pre -Authorization and Medical Billing Instructions, for details.
Section 3.5.1 Contractor Responsibilities.
3.5.1.1 The Contractor will provide Department Sentenced Felons in its facility
with care that is identical to the care provided to Contractor inmates. The
Contractor will provide twenty-four (24) hour access to emergency medical
care and the most cost-effective, medically appropriate methods of
transportation and security for all Sentenced Felons taken out of the Facility
for off-site medical care.
3.5.1.2 Begintung on day 8, the Contractor is not required to call the DOC 24/7
Nurse Desk for pre -authorization for off-site medical visits or trips to the
hospital for a medical emergency. The Contractor is; however, as a courtesy,
asked to inform the DOC Nurse Desk NurseDesk@(iocl.wa.gov or (360)
725-8733, as soon as possible when a DOC Sentenced Felon is taken off-site
for medical care.
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3.5.1.3 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.
3.5.1.4 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 Sentenced Felons, or for care
which could have foreseeably been prevented
3.5.1.5 The Contractor will be financially responsible for any medical costs
incurred due to the negligent action or inaction of Contractor's employees.
Section 3.5.2 Department Responsibilities
3.5.2.1 Beginning on the 811, day that a Sentenced Felon is housed in Contractor's
facility the Department will be financially responsible for extraordinary
medical care provided to the Sentenced Felon, provided that it is consistent
with this Contract and the FIR
3.5.2.2 Beginning on the 81h day that a Sentenced Felon is housed in Contractor's
facility the Department will be financially responsible for the cost of
prescription medications administered to that individual. The Department
will not be responsible for the cost of any over-the-counter medications.
3.5.2.3 If the Sentenced Felon 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.
Section 3.5.3 Safe Transfer of Care.
3.5.3.1 HIPAA — Both parties agree to follow the Health Insurance Portability and
Accountability Act of 1996 (HIPAA). HIPPA protects the 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 CFR45 § 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.
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Department of Corrections
3.5.3.2 The Contractor agrees to consult with the medical staff at any DOC reception
center or prison receiving the Sentenced Felon and to provide records,
current care instructions, and all appropriately labeled medications to the
Department at the time of Department transfer.
Section 3.5.4 Medical Billine. Contractor medical costs incurred for a Sentenced Felon's
medical care not included in the per diem rate may be reimbursed by the Department
consistent with this Contract. (See Attachment B, Pre -authorization and Medical Billing
Instructions and Attachment C, Sample Medical Billing Reimbursement Form.)
Each itemized bill must contain the Sentenced Felon's name and supporting documentation of
the service provided that includes date(s) of service, name of the practitioner who ordered the
service, details of the service/item(s) provided, prescriptions(s) provided, the facility(s) that
provided the service(s), and a copy of any health care claims paid to off-site providers. (See
Attachment C, Sample Medical Billing Reimbursement Form)
All reimbursements claims must also include documentation showing proof of payment by
the Contractor. 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 will submit itemized bills for medical services to DOC within 365 days after
the date of service.
Section 3.6 Contract Coordinator. Each party will identify a coordinator who is responsible for
administering the Contract on behalf of that party.
For DOC: Greg Oliver, Violator Manager, CCD, gjoliverCDOC1.WA.G0V, 360.584.3202
For County: Darius Harmon, dbharmon(nwrantcountywa.gov, (509) 754-2011 ext: 2482
Section 3.7 Offender Programs. DOC Sentenced Felons will not have access to any
programming that Contractor may provide to its own inmates.
Section 3.8 Orientation. Upon arrival at the Facility, if not provided prior to sentencing, the
Contractor will fingerprint and provide an orientation for Sentenced Felons. This must include 1)
facility rules and disciplinary procedures; 2) medical care availability; and 3) visitation rules.
Section 3.9 Clothin¢.
Section 3.9.1 Clothing and bedding for Sentenced Felons will be provided and maintained
in accordance with the Facility's policies.
Section 3.9.2 The Contractor will furnish climate appropriate outerwear comparable to that
provided to Contractor inmates.
Section 3.10 Programming. The Contractor will not be responsible for DOC intake assessments
or correctional programming. Those responsibilities will remain with the Department.
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Department of Corrections
3.5.3.2 The Contractor agrees to consult with the medical staff at any DOC reception
center or prison receiving the Sentenced Felon and to provide records,
current care instructions, and all appropriately labeled medications to the
Department at the time of Department transfer.
Section 3.5.4 Medical Billing. Contractor medical costs incurred for a Sentenced Felon's
medical care not included in the per diem rate may be reimbursed by the Department
consistent with this Contract. (See Attachment B, Pre -authorization and Medical Billing
Instructions and Attachment C, Sample Medical Billing Reimbursement Forn1.)
Each itemized bill must contain the Sentenced Felon's name and supporting documentation of
the service provided that includes date(s) of service, name of the practitioner who ordered the
service, details of the service/item(s) provided, prescriptions(s) provided, the facility(s) that
provided the service(s), and a copy of any health care claims paid to off-site providers. (See
Attachment C, Sample Medical Billing Reimbursement Form)
All reimbursements claims must also include documentation showing proof of payment by
the Contractor. 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 will submit itemized bills for medical services to DOC within 365 days after
the date of service.
Section 3.6 Contract Coordinator. Each party will identify a coordinator who is responsible for
administering the Contract on behalf of that party.
For DOC: Greg Oliver, Violator Manager, CCD, gjobver@DOCI.WA.GOV, 360.584.3202
For County: Gnsert name, title, email & phone)
Section 3.7 Offender Programs. DOC Sentenced Felons will not have access to any
programming that Contractor may provide to its own inmates.
Section 3.8 Orientation. Upon arrival at the Facility, if not provided prior to sentencing, the
Contractor will fingerprint and provide an orientation for Sentenced Felons. This must include 1)
facility rules and disciplinary procedures; 2) medical care availability; and 3) visitation rules.
Section 3.9 Clothing.
Section 3.9.1 Clothing and bedding for Sentenced Felons will be provided and maintained
in accordance with the Facility's policies.
Section 3.9.2 The Contractor will furnish climate appropriate outerwear comparable to that
provided to Contractor inmates.
Section 3.10 Programming. The Contractor will not be responsible for DOC intake assessments
or correctional programming. Those responsibilities will remain with the Department.
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Department of Corrections
Section 3.11 Death of an Offender. The Contractor will immediately notify the DOC Contract
Coordinator of the death of any Sentenced Felon. The Contractor will provide the Department
with certified copies of the Sentenced Felon's death certificate.
Section 3.12 Escape. The Contractor will immediately notify the DOC Contract Coordinator if a
Sentenced Felon escapes.
Article IV PERSONNEL
Section 4.1 Independent Contractor. Each party to this Contract will perform its duties
hereunder as an independent contractor and not as an employee of the other party. Neither the
Contractor nor any agent or employee of the Contractor shall be deemed to be an agent or employee
of the Department. Neither the Department nor any agent or employee of the Department shall be
deemed to be an agent or employee of the Contractor.
Article V MISCELLANEOUS
Section 5.1 Existing State Law. This Contract will not be construed to alter the responsibilities
of the Contractor or the Department with regard to the legal and fiscal responsibility for
confinement, care, and treatment of Sentenced Felons under state law.
Section 5.2 Disputes. Disputes between the parties will be handled between the contract
coordinators for both parties. If an agreement that is satisfactory to both parties cannot be reached
then the dispute will escalate to the next highest level. If still not resolved, then each party will
determine the position in each organization to which the dispute must be escalated for resolution.
Nothing in this section is intended to limit either party access to any and all courts of law of this
state or country.
Section 5.3 Equal Employment Opportunity. The parties ascribe to the principles of equal
employment opportunity. Neither is responsible for ensuring that the other is in compliance with
equal employment statutes or policies.
Section 5.4 Invalidity and Severability. The terms of this Contract are severable and should
any tern or provision hereof be declared invalid or become inoperative for any reason, such
invalidity or failure shall not affect the validity of any other term or provision hereof. In the event
that any provision of this Contract is held invalid, that provision shall be null and void. However,
the validity of the remaining provisions of the Contract shall not be affected thereby.
Section 5.5 Jurisdiction. and Venue. The laws of the State of Washington and the rules and
regulations issued pursuant thereto shall be applied in the interpretation, execution and
enforcement of this Contract. Venue for any legal action related to the performance or
interpretation of this Contract shall be in the Superior Court in Thurston County, Washington.
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Department of Corrections
Section 5.6 Scope of Contract. This Contract and any appendices or exhibits to it incorporate
all the contracts, covenants, and understandings between the parties. No prior contract or
understandings, verbal or otherwise, of the parties or their agents shall be valid or enforceable
unless embodied in this Contract. This Contract shall not be altered, changed, or amended except
by mutual consent of the parties in writing.
Section 5.7 Compliance with Applicable Laws. The parties agree at all times during the
performance of their obligations under this Contract to strictly adhere to all applicable federal and
state laws and regulations.
THIS CONTRACT, consisting of seventeen (17) pages and four (4) attachments, is executed by the persons
signing below who warrant that they have the authority to execute the Contract.
GRANT COUNTY
Tom Jones 12/22/2020
Sheriff
State of Washington
Department of Corrections
WASHINGTON STATE
DEPARTMENT OF CORRECTIONS
Debra Eisen
Contracts Administrator
Date
Tim Lang, Senior Assistant Attorney General
Approved by:
The Office of the WA State Attorney General
December 18, 2020
Page 9 of 17
FOR COUNTY USF.
PLEASE FORMAT AND USF THIS PAGE FOR COMMISSIONLR. SIGNATURES AS
REQUIRED BY YOUR OWN JURISDICTION
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Cindy Carter, mair
Tom Taylor, ice Chair
Richard Stevens, Member
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Department of C—ti—1
Attachment A
DOC Contact Information
DOC Contract Coordinator
Greg Oliver
■ Contract concerns/issues
Monday -Friday (except Holidays): 8:00 am -5:00 pin
■ Death of a Sentenced Felon
■ Work 360-725-8943
■ Escape
■ After hours/holidays 360-584-3202
■ gregory.oliver@doc.wa.gov
Medical Issues
DOC Nurse Desk -24/7
Inform of extraordinary or off-site
• 360-725-8733
medical care that occurs.
Additional contact during business hours:
• NurseDesk@ydocl.wa.gov
• Fax: 360-586-9060
Medical Billing
Medical Disbursement Unit
■ Requests for reimbursement for off-
■ DOCHOMedicalRAB@docl.wa.gov
site and emergency medical care not
■ 360-725-8298
included in the per diem rate.
■ Fax: 360-586-1320
Concerns after normal business hours
DOC Warrants Desk -24/7
(For referral to the appropriate Duty Officer)
■ 360-725-8888
Pending DOC Transfer Lists
Reception Center Contacts
■ For males, Washington Corrections Center at
Send list of incoming DOC
docdlwccrecords@doc.wa.sov.
admissions to Reception Center
- For females, Washington Corrections Center
Contacts by close of business on
for Women at docdlwccwrecords@doc.wa.gov.
12/23/2020 and 12/30/2020.
- Tina Burgess, Records Manager at
tina.burgess@doc.wa.gov or 360-529-7514.
Submit Per -Diem Bill
Contact
Send itemized bill to DOC for dates
- Washington Corrections Center at
of requested payment. Please use
docdlwccrecords@doc.wa.sov.
Attachment D for er-Diem billing.
- Tina Burgess, Records Manager at
tina.burgess(cpt�,doc.wa.sov or 360-529-7514.
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Department of Corrections Attachment A
Medical Billing Instructions
Beginning on the 8th Day at County Jail
Definitions
Attachment B
Basic Per Diem Rate — the cost per day per Sentenced Felon for all care, including in -facility
medical care, which is the same or similar care provided to County inmates.
DOC Utilization Management Office (Nurse Desk) — the Department's medical contact that
receives extraordinary medical expenses for DOC Sentenced Felons. The Nurse Desk is
available 24 hours a day at (360) 725-8733 or during normal business hours via email at
NLn-seDesk@jc1ocl.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 per diem rate for in -facility care for Sentenced Felons.
In -Facility Care — medical care provided to Sentenced Felons as part of the per diem rate 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 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:
littp://www.(ioc.wa.gov/corrections/services/docs/formulary pdf.
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
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Department of Corrections Attachment B
■ 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
■ 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
■ Be administered solely for the convenience of the Sentenced Felon 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 Health Plan
(HP) as not medically necessary
■ Brand-name medication when a generic product is available within the therapeutic class
Health Plan (HP) — The Department's HP describes medically necessary medical care, mental
health and dental care services that are available to individuals under Department jurisdiction
as well as services that are limited or not available. The HP is not a guarantee of payment for
services provided to Sentenced Felons. The Health Plan (HP) is available online at the following
link: http://doc.wa.gov/corrections/services/healtli.litm.
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.
Courtesy Notification
The County is requested to notify the Department's Nurse Desk when housing Sentenced
Felons who are on specialty/high cost medications for long-term or chronic conditions such as
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Department of Corrections Attachment B
Hepatitis C, HIV, MS or any other condition that requires the consistent administration of
medications during their incarceration. The Department requests notification of the need for
specialty/high cost medications before the 81h day of confinement so that the necessary
medication maybe procured in the most cost-effective manner.
The Contractor is requested, as a courtesy, to inform the Department Nurse Desk,
NurseDesk@docl.wa,gov or (360) 725-8733 when a Sentenced Felon is taken off-site for
emergency or other medical care.
Medicaid. Coverage - 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 will not be billed for qualifying services. However, the County 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 Nurse Desk will be available by phone 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.wa.gov or (360) 725-8733. (After normal business hours and during
holidays, the call will forward to the on-call Nurse.)
Medical Billing - The County is responsible for processing payment for all bills prior to sending
them to the Department for reimbursement. However, if the County is unable to make payment
for direct billings, the County may send a written request to the Department to process
payment on the behalf of the County. Such request can be submitted by fax (360) 586-1320 or
email to DOCHOMedicalRAB(a_)DOCI.IWA.GOV. The County must include a copy of the bill
with its request. The Department will respond to written requests for assistance with payment
of direct billings within seven (7) business days of receipt.
Please do not instruct the billing entity to bill the Department directly.
Itemized invoices for reimbursable medical services are to be submitted electronically to the
Medical Disbursement Unit at DOCHOMedicalRAB@DOCI.WA.GOV.
Any billing for offsite services should be submitted to DOC for reimbursement or payment
within 30 days of the receipt of the bill and within 365 days of the date of service. Itemized
statements must be submitted in the format below with supporting documentation when
applicable. Statements that are 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:
State of Washington K Page 14 of 17
Department of Corrections Attachment B
The County bill must include:
Reason
Split Amount
Trip Date
IP? for
Last
First
DOC # or
or date
Destination or RX name &
name
Name
Birthdate
RX given
strength
Doe
John
999999
8/27/12
Gabapentin 30 MG TAB
Jackson Joseph
111111
8/1/12
Clonidine 1 NIG TAB
Smith
Joe
888888
8/14/12
Providence St Peter Hospital
The County bill must include:
■ A coversheet with all pertinent details including the total amount billed, dates of service,
County/facility name, billing personnel contact information (email, phone number and
fax), address to send payment, the County's internal invoice/tracking number and
County Federal Tax ID number.
■ Itemized Charges including the name of the Sentenced Felon who received the care, the
care received, and the cost. For reimbursement for payments to offsite providers, a copy
of the original healthcare claim form paid by the facility must be included. For onsite
services, the details of services provided must be listed along with copies of any paid
bills and the amounts attributed to each DOC Sentenced Felon.
■ For medications, County must provide a copy of the pharmacy bill to include the drug
name, dosage, quantity provided and the amount County paid for the dregs.
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 K Page 15 of 17
Department of Corrections Attachment B
Reason
Split Amount
ER?
IP? for
Custody Billed to
Quantity (YIN)
(YIN) TripIRX #
(YIN) DOC
14 N
N
N 25.00
6 N
N
N 34.00
Y
N Broken Leg
2,500.00
■ A coversheet with all pertinent details including the total amount billed, dates of service,
County/facility name, billing personnel contact information (email, phone number and
fax), address to send payment, the County's internal invoice/tracking number and
County Federal Tax ID number.
■ Itemized Charges including the name of the Sentenced Felon who received the care, the
care received, and the cost. For reimbursement for payments to offsite providers, a copy
of the original healthcare claim form paid by the facility must be included. For onsite
services, the details of services provided must be listed along with copies of any paid
bills and the amounts attributed to each DOC Sentenced Felon.
■ For medications, County must provide a copy of the pharmacy bill to include the drug
name, dosage, quantity provided and the amount County paid for the dregs.
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 K Page 15 of 17
Department of Corrections Attachment B
Department of Corrections
Name of County & Jail
( Mailing Address )
( Phone Number
(Email Address )
Sentenced Felon Per Diem Invoice
Service Dates: through _
Total Amount ($00.00)
Beainnina Dav 8 - Per Diem Rate: $ 93.71
Days 1 — 7 for Prison DOSA & CCP Returns - Current negotiated violator rate:
Attachment C
Sample Medical Billing Reimbursement Form
Bill to:
Washington State Department of Corrections
P.O. Box 41 149
Olympia, WA 98504 (360) 725-8620
DOCViolatorbedbiIIirw(i-rDOC I .WA.GOV
Name
- -
DOC #
DOB
DOC start date
Sanction/Confinement
DCX: End/Transt'er date
for SanctiomlConfmcment
Total # of billed DOC
Das
Total amount billed to
DOC
Doe. Jane
123456
1/15/89
7/19/15
7/21/15
2
$130.00
Smith. Johnny
121212
2/26/62
7/8/15
7/20/15
12
$780.00
Jahnsen, Doe
5555555
10/31/92
8/1/15
811115
-1
-$65.00
TO'T'AL
paid by
billed to
13
$845.00
Last
First
DOC#
Date of
Date of
Medical
RX
RX # or
Name of
Date and
Name of
Copy of
Copy of off-
Amount
Amount
Name
Name
Birth
Service
Facility or
gn:mtlty
reason for
jail staff
time of
DOC
approved
site medical
paid by
billed to
12X name,
or # of
treatment
contacted
contact with
medical
"oil-
provider
contractor
DOC
& strength
days
DOC
medical
staff
formulary
claim form
medical
staff
contacted
request
andror
I
staff
attached, if
Contractor's
available?
original
Y, N or N1A
pharmacy
bill attached
as required'!
Y/N
Doe
Jane
123456
1/15/89
7/20/15
Gabapentin
3 pills
1234561
Elmer
7/20/15,
Tammy
Y
Y
$12.50
$11.50
30 MG "fab
Phud
12:34 pro
Williams
Smith
Johnny
121212
2/16/62
7/10/15
St Joseph's
7 days
Chest pain
Erin
7110/15,
Lisa Russell-
N/A
Y
$2,500.00
$2,500.00
Hospital
Ro gcrs
2:40 am
Tufty
Jahnsen
Doe
555555
10/31/92
811115
Walla -Walla
5 weeks
Foreign
Billie
811115:
Sarah
N/A
Pendine
$5,000.00
$4,996.00
General
object
Goat
4:10 pm
Nichols
1-1os ital
removal
State of Washington K Page 16 of 17
Department of Corrections Attachment C
Attachment n
AT'T'ACHMENT D
PER -DIEM BILLING FORM
130C: if
Lam Name Firsl Name Knamvn --Pat c of Birth
Gender SID:
Cause Number (s) BookingDate
Date of
Sentenre
Date
Transferred
to DOC
Dates Requesling
Payment
I
State of Washington K Page 17 of 17
Department of Corrections Attachment D