CCR1994019COMMON COUNCIL - CITY OF MUSKEG0
RESOLUTION #19-94
APPROVAL OF RENEWAL OF WISCONSIN MEDICAL ASSISTANCE
PROGRAM PROVIDER AGREEMENT
(Rescue Service)
WHEREAS, the City of Muskego is reimbursed for rescue services
provided to individuals under Title XIX because we are a
certified provider; and
WHEREAS, the State of Wisconsin, Department of Health and Social
Services is requiring recertification this year in order to
update their records and include provisions regarding ADA.
NOW, THEREFORE, BE IT RESOLVED that the Common Council of the
City of Muskego, upon the recommendation of the Finance
Committee, does hereby approve the renewal of the State of
Wisconsin, Department of Health and Social Services, Wisconsin
Medical Assistance Program Provider Agreement, as attached, to
under Title XIX.
receive reimbursement for rescue services provided to individuals
DATED THIS 25TH DAY OF JANUARY , 1994.
SPONSORED BY:
FINANCE COMMITTEE
Ald. Patrick A. Patterson
Ald. Edwin P. Dumke
Ald. David J. Sanders
This is to certify that this is a true and accurate copy of
City of Muskego.
Resolution #19-94 which was adopted by the Common Council of the
1/94 jmb
Tommy G. Thompson
State of Wisconsin
Secretary Department of Health and Social Services
DOH 11 11 A (Rev. 12/93)
DHSS/HEALTH
Wis. Adm. Code HSS 105.01
DIVISION OF HEALTH
1 WEST WILSON STREEl
MADISON WI 53701-0309
P. 0. BOX 309
STATE OF WISCONSIN
DEPARTMENT OF HEALTH AND SOCIAL SERVICES
WISCONSIN MEDICAL ASSISTANCE PROGRAM PROVIDER AGREEMENT
(For non-institutional and institutional providers)
The State of Wisconsin, Department of Health and Social Services, hereinafter referred
to as the Department, hereby enters into an agreement with
Provider's Name land Number, if assigned) Name must match applicant (new) or existing record Irecertificationl
a provider of health care services, hereinafter referred to as the Provider, to provide
services under Wisconsin's Medical Assistance Program, subject to the following
terms and conditions:
1.
2.
3.
4.
The Provider shall comply with all federal laws, including laws relating to Title
XIX of the Social Security Act, State laws pertinent to Wisconsin's Medical
Assistance Program, official written policy as transmitted to the provider in the
Wisconsin Medical Assistance Program Handbooks and Bulletins, the Civil
Rights Act of 1964, the Age Discrimination in Employment Act of 1967, the
Age Discrimination Act of 1975, the Department of Health and Social Services
Standards for Equal Opportunity in Service Delivery, section 504 of the
Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990, and
the Wisconsin Fair Employment Law, as are now in effect or as may later be
amended.
The Department shall reimburse the Provider for services and items properly
provided under the program in accordance with the "Terms of Reimbursement"
attached hereto and incorporated herein by reference, as are now in effect or as
may later be amended.
In accordance with 42 CFR s. 431 107 of the federal Medicaid regulations, the
Provider agrees to keep any records necessary to disclose the extent of services
provided to recipients, upon request, and to furnish to the Department, the
Secretary of the federal Department of Health and Human Services, or the state
Medicaid Fraud Control Unit, any information regarding services provided and
payments claimed by the provider for furnishing services under the Wisconsin
Medical Assistance Program.
The Provider agrees to comply with the disclosure requirements of 42 CFR Part
455, Subpart 6, as now in effect or as may be amended. The Provider shall
furnish to the Department in writing:
(a) the names and addresses of all vendors of drugs, medical supplies or
transportation, or other providers in which it has a controlling interest or
ownership;
(b) the names and addresses of all persons who have a controlling interest in
the provider;
-1 -
(c) whether any of the persons named in compliance with (a) and (b) above
are related to another as spouse, parent, child, or sibling;
(dl the names, addresses, and any significant business transactions between
the provider and any subcontractor;
(e) the identity of any person who has been convicted of a criminal offense
related to that person’s involvement in any program under Medicare,
Medicaid or Title XIX services programs since the inception of those
programs.
5. The Provider hereby affirms that it and each person employed by it for the
purpose of providing services holds all licenses or similar entitlements as
specified in HSS 101 to 108 and required by federal or state statute, regulation,
or rule for the provision of the service.
6. The Provider consents to the use of statistical sampling and extrapolation as the
means to determine the amounts owed by the provider to the Wisconsin
Medical Assistance Program as a result of an investigation or audit conducted
by the Department, the Department of Justice Medicaid Fraud Control Unit, the
federal Department of Health and Human Services, the Federal Bureau of
Investigation, or an authorized agent of any of these.
7 Unless earlier terminated as provided in paragraph 8 below, this agreement shall
expiring annually on March 31. Renewal shall be governed by s. HSS
remain in full force and effect for a maximum of one year, with the agreement
105.02(8), Wisconsin Administrative Code.
8. This agreement may be terminated as follows:
(a) By the provider as provided at s. HSS 106.05, Wisconsin Administrative
(b) By the Department upon grounds set forth at s. HSS 106.06, Wisconsin
Code.
Administrative Code.
DOH 1 1 1 1 A (Rev. 12/93) - 2.
,.
, ,
STATE OF WISCONSIN
AND SOCIAL SERVICES
Name of Provider (Typed or Printed) DEPARTMENT OF HEALTH
Address
City State Zip
BY.
Signature of Provider
TITLE: BY:
DATE: DATE:
MODIFICATIONS TO THIS AGREEMENT CANNOT AND WILL NOT BE AGREED TO.
THIS AGREEMENT IS NOT TRANSFERABLE OR ASSIGNABLE.
Below, please fill in the address where your countersigned provider agreement is to be
returned.
PRINT CLEARLY, THIS IS YOUR MAILING LABEL.