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Home My WebLink About260335 06/28/16 CITY OF CARMEL, INDIANA VENDOR: 370756 ONE CIVIC SQUARE TREASURER STATE OF INDIANA CHECK AMOUNT: $****27,307.56' x =� CARMEL, INDIANA 46032 INDIANA FSSA CHECK NUMBER: 260335 Mirua moo`- 13992 COLLECTIONS CENTER DR CHECK DATE: 06/28/16 CHICAGO IL 60693 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 101 5023990 06172016 27,307.56 OTHER EXPENSES VOUCHER NO. WARRANT NO. 6kS7WO /�Q/� ' ALLOWED 20 IN SUM OF $ lle_Li ns X�Wlt $ a77 �� ON ACCOUNT OF APPROPRIATION FOR Board Members Po#or INVOICE NO. ACCT#/TITLE AMOUNT DEPT.# I hereby certify that the attached invoice(s), D J�D�?3 a7. D7,56 or bill(s) is (are) true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except 20 Itntire Cost distribution ledger classification if Title claim paid motor vehicle highway fund MYERSAND ® STAUFFEIZLC CERTIFIED PUBLIC ACCOUNTANTS June 17, 2016 David G. Haboush City of Carmel Fire Department-Ambulance Service, 2 Civic Square Carmel, IN 46032 RE: 2013 Ambulance Payment Adjustment for Managed Care Services UPS Tracking Number-'1Z 9V1 W32 03 9346 5356 Dear Provider, A cover letter, notice of program reimbursement,:and payment agreement were issued to you on June 10, 2016 that communicated the 2013 ambulance payment adjustment for managed care services. Please note that due to the volume of incoming checks, we are requesting that the checks - bemailed directly to:the Indiana Family and Social Services Administration: Please make checks payable to thelTFeasurer of the State of India and`send-to the address noted below. Indiana Family and Social Services Administration 13992 Collections Center Drive Chicago fL-_60693' _ Please enclose a copy of the signed payment agreement with the check to the address above. Additionally, please send a copy:of the signed payment agreement to Myers and Stauffer LC at the following address. You may also email the signed payment.agreement to ambulance@msic.com. Myers and Stauffer LC Attn: .Berry Bingaman 9265 Counselors Row, Suite 100 -Indianapolis, IN 46240 If you have already mailed a copy of the payment agreement and check to Myers and Stauffer LC; please disregard this notice. We appreciate and value your participation in the Medicaid.-program and the care you render its recipients. Should you have any.questions;.please do.not hesitate to contact Myers and Stauffer by telephone at 800-877=6927 or 317-846-9521. Sincerely; Berry Bingaman, CPA Myers andStauffer LC DEDICATED TO GOVERNMENT HEALTH PROGRAMS 9265 Counselors Row,Ste 100 Indianapolis, IN 46240 PH 317.846.9521 I PH 800.877.6927_1 Fx 371.571:8481 www.mslc.com YERSAND 1441 STAUFFER,, CERTIFIED PUBLIC ACC00NTANTS June 10, 2016 . David G. Haboush City of Carmel Fire Department 2 Civic Square Carmel, IN 46032 RE: 2013 Amb la Payment Adjustment for Managed Care Services UPS Tracking Number-1Z 9V1 W32 03 9030 4427 Dear Provider, As you know; the Office of Medicaid Policy and Planning(OMPP)provides a payment adjustment to qualified in-state government-owned ambulance providers. The payment adjustment is intended to reimburse in-state government=owned ambulance providers the actual incurred costs of providing ambulance services to.eligible Indiana Medicaid beneficiaries. The payment adjustment originally included only.Medicaid ambulance services provided to beneficiaries under the Medicaid fee-for-service.program. The payment adjustment-is being expanded to also reimburse in-state government-owned ambulance providers for services provided to Medicaid managed care beneficiaries. The Medicaid fee-for-service payment adjustment is effective_for dates of-service on or after January 1, 2011. The Medicaid.managed care payment adjustment is effective for dates of service on or after.Jan uary1, 2013 and will be paid on a calendar yearbasis. This letter communicates the managed care payment for calendar year 2013. A provider-specific cost-to-charge ratio was developed based,upon 6-review of your fiscal year ended 2013. Indiana Medicaid Freestanding Governmental Ambulance Providercost report. This cost-to-charge ratio was utilized to calculate the ambulance payment adjustment for Medicaid managed care ambulance services for calendar:year 2013. These payments will be made by the state's contracted managed care entities during calendar year 2016. Similar to other Medicaid payments, the ambulance payment adjustment is funded in part by the federal government(federal share)and in part through non-federal (state or local)funds. The federal portion is referred to-as the federal share, and the non-federal portion is referred to as,the non-federal share. The OMPP has determined that the non-federal share of the Medicaid managed care ambulance payment adjustment will be made through the use of an intergovernmental transfer :(IGT)funding mechanism. An IGT is the transfer of funds from one unit of government to-another.. In order to receive the Medicaid managed care ambulance payment adjustment, the non-federal share must be supplied by the ambulance provider.- The payment is structured as follows: 1) The providerwill issue a payment to the OMPP for the non-federal (state)share of the ambulance payment adjustment. DEDICATED TO GOVERNMENT HEALTH PROGRAMS 9265 Counselors Row,Ste 100,1 Indianapolis,IN 46240 PH 317.846.9521 I PH 800.877.6927 fx371.571.8481 . www.mslc.com - - AGREEMENT BETWEEN,THE CITY OF CARMEL FIRE DEPARTMENT AND THE STATE OF INDIANA FOR ITS 2013 GOVERNMENTAL AMBULANCE PAYMENT ADJUSTMENT FOR MANAGED CARE SERVICES This Agreement is entered into.by the City of Carmel Fire Department of Hamilton County, Indiana(".Provider"-),a governmental ambulance provider,and the State of Indiana,through the Family and Social Services Administration,Office of Medicaid Policy and Planning("OMPP"of"the State"), This Agreement_is air amendment to the Indiana Health Coverage Programs(IHCP)Provider Agreement for the City of Cannel Fire Department. WHEREAS, in June 2016 the Provider will make a permissible intergovernmental-transfer (IGT) of funds in order to fund the Fiscal Year 2013 Govenimental.Ambulance Payment Adjustment for managed care services (the '.'Payments"). The Payments will be paid to.Provider in 2016 by the state's contracted managed care entities;and. WHEREAS, the-Provider and the State recognize that the Centers for Medicare & Medicaid. Services("CMS") has the authority to determine whether the Payments are Medicaid expenditures of finds,which are eligible for federal financial participation("FFP'); NOW,THEREFORE,in consideration of the mutual promises and covenants contained herein, it is hereby agreed as follows: 1. The Provider will make an IGT.of funds via check in the amount of Twenty-Seven Thousand Three Hundred Seven Dollars and Fifty-Six Cents($27,307.56),which are not federal finds,or are federal funds authorized by federal law to match other federal funds. 2. .. . .The State's Payment to the Provider will be.made by the state's contracted managed care entities in the amount of Eighty-One Thousand Sia:Hundred Seventeen Dollars and Seventy-One Cents($81,617:71),the total amount. 3. The Provider will:retain one hundred percent (10.0%) of the.Payment described in Paragraph 2,above. 4. In the event that the State is,notified by CMS that FFP,will not be, recognized;CMS. defers the State's claim for FFP,or CMS issues a notice of disallowance,the Provider shall do the following: (a) If CMS defers the State's claim for FFP for any reason, the Provider shall provide to the State:any and all information.requested by CMS to support the claim and resolve the deferral. 'The parties agree that the State has no responsibility, other than to submit information-to CMS that is,provided by the Provider,to attempt to resolve the deferral in favor of the Provider. (b) If CMS issues a notice of disallowance,the Provider shall,within`fifteen(15) calendar days after notification by the State that CMS has declined to approve the Payments.for purposes of FFP eligibility:deliver to the State funds in the amount -.of Eighty-One Thousand Six Hundred Seventeen Dollars and Seventy--One Cents ($81;617.71). Such payment shall be the amount of the Provider's ambulance payment adjustment described in Paragraph 2,above: (c) The Provider shall waive any appeal based on the CMS determination to: disallow FFP for the Provider's Payments. Such waiver`shall include any demands of payment or offset against_claims by the State. City of Carmel Fire Department June 10,2016 ..Page 2 of 2_ The cover letter must include your facility's name and address and your federal tax identification number. You will receive your Indiana Medicaid Governmental Ambulance Payment Adjustment for managed care services for calendaryear 2013 after this information has been received APPEAL SECTION This notification constitutes an appealable,order. If you disagree with this determination, you have the right to appeal under 405.IAC 1-1,,5.-In order to assert your appeal rights, you must file an appeal request within fifteen (15)days of your receipt of this letter. The appeal request must state that you are the party.to.whom the order is specifically directed; that you are adversely.affected by . the determination; and that you'are entitled to review under the law. Please refer to the rule for further information on your.appeal rights. Appeals should be sent to the following address: Dr..John J.Wernert,Secretary MS07-Office-of Medicaid Policy.and Planning . . ATTN: Mr. Chris Fletcher 402 West Washington RoomW382 Indianapolis, IN 46204 A copy of this notice must accompany your appeal request: A copy of the appeal should also be sent to Myers and Stauffer LC at the address listed below. Failure to file an appeal request within fifteen (15)days from receipt of.this letter will result in the waiver of any right to appeal this determination. - If you elect to appeal this determination, you must also.file a statement of issues within forty-five (45) days after you receive notice of this determination. The statement of issues=shouId be sent to the same.address as the appeal request. The statement of issues should conform to 405 IAC 1--1.5-2 (e). The statement of issues and the,appeal request may be filed together. Please also forward a copy of the statement of issues to Myers and Stauffer LC.at the following address: Myers and Stauffer LC -Attn: Berry Bingaman.: 9265 Counselors Row, Suite 100 Indianapolis, IN. 46.240 If you elect to waive your right.to an appeal, please fax or mail such notification to Berry Bingarnan, in care of Myers-and Stauffer LC. The fax telephone number is(317)571-8481. incerely, Q7V�� V Berry Bingaman, CPA Myers anal Stauffer LC cc: Jennifer White, DMPP Enclosure Report: CLM-0113-F4 INDIANA FAMILY PND SOCIAL SERVICES ADMINISTRATION DATE: 03/29/2016 Process: FN103011 INDIANA HEALTH COVERAGE PROGRAMS TIME: 23:42:36 Location: FTNJ11200 SERVICED BY HP PAGE: 6 PROVIDER REMITTANCE ADVICE PROFESSIONAL SERVICES CLAIMS PAID 200124160 A 1154325579 CITY OF CARAMEL FIRE DEPARTMENT CHECK/EFT NUMBER 904839460 2 CIVIC SQ CARMEL IN 46032 2584 RECIFIENT SERVICE DATES NAME RID NO. I'IN PATIENT K-uMBER FROM TP."RU BILLED TPI, PATIENT RESP aAIJ MADDEN C D 100609023599 2116081600322 20161274-1 031016 031016 511.00 0.00 0.00 120.77 PL PROC MODIFIERS UNITS PROVIDER 41 A0429 RH 1.000 1154325579 031016 031016 475.00 0.00 110.84 41 A0425 U2 3.000 1154325579 031016 031016 36.00 0.00 9.93 BOBS 000 9092 001 9048 002 9048 ARCS 001 45 354.16 002 45 26.07 REMARKS 001 N14 002 N14 MADDEN C D 1006090.23599 2116081600323 20161296-1 031116 031116. _ 530.20 0.00 0.00 126.07 PL PROC MODIFIERS UNITS PROVIDER 41 A0429 RH 1.000 1154325575, 0312.16 031116 475.00 0.00 110.84 41 A0425 U2 4.600 1154325579` 031116.031116 55.20 0.00 15.23 BOBS 000 9092 Doi. 9048 002 9048 ARCS 001 45 364.16 002 45 39.97 REMARKS 001 N14 002 N14 MADDEN C D 100609023599 2116083600369 201.61359-1 031.516 031516 529.00 0.00 0.00 1.25.74 ?L PROC MODIFIERS UNITS PROVIDER 41 A0429 RH 1.000 1154325579 031516 C31516 475.00 0.00 110.84 91 A0425 U2 4.500 115432579 031516 031516 54.00 0.00 14.90 BOBS 000 9092 001 9048 002 9048 ARCS 001 45 364.15 C01 45 n REMARKS 001 N14 002 N14 TOTAL PROFESSIONAL SERVICES CLAIMS PAID: 1,570.20 0.00 0.00 372.58 Report: CL111.4-0000-tk IHTIrANA FAMILY AND SOCIAL SERVICES ADMINISTRATION DATE: 03;29(2016 Process: FNIO3011 INDIANA HEALTH COVERAGE PROGRAMS TIME: 23:42:36 Location: FINJW200 SERVICED 3Y HP PAGE: 8 PROVIDER REMITTANCE ADVICE FINANCIAL TRANSACTIONS 204124160 A /154325579 CITY OF CARMEL FIRE DEPILR7-MENT CHECK/EFT NUMBER 904839460 2 CIVIC SO CARMEL IN 46032 2584 SPECIFIC PAYOUTS TO PROVIDERS ---------------NON-CLAIM SPECIFIC REFUNDS FROM PROVIDERS--------------- IRAN SACTTON PAYOUT REASON FIN REFUND REASON FIN NUMBER --CCN-- AMOUNT CODE ARC --CCN-- AMOUNT CODE ARC RECIPIENT NAME RID NO. 490765 186,603.31 8774 CS NO NON-CLAIM SPECIFIC REFUNDS FROM PROVIDERS TOTAL NON-CLAIM SPECIFIC PAYOU`iS TO PROVIDERS :186,603-31. ----------------------------------ACCOUNTS RECEZJABLE-------------------------------------- SETUP ORIGINAL REASON FIN ORIGINAL AjR NUMBER DATE AMOUNT BALANCE CODE ARC --ICN-- RID NO. RECIPIENT NAME NO OUTSTANDING ACCOUNTS RECEIVABLE Report; CLM-0148-W INDIANA FAMILY AND SOCIAL .SERVICES ADMINISTRATION DATE: 03/291'2016 Process: FNZO3011 I INDIANA HEALTH COVERAGE PROGRAMS TIME: 23:42:36 Location: FINJI4200 SERVICED BY HP PAGE: it PROVIDER_ REMITTANCE ADVICE SUMMARY iARY 200124160 A 1154325579 CITY OF CARMEL FIRE DEPARTMENT CHECKJEFT NUMBER 904839460 2 CIVIC SQ CARMEL IN 46032 2584 ------------CLAIMS DATA------------ CURRENT CURRENT YEAR-TO-DATE YEAR-TO-DATE NUMBER AMOUNT NUMBER AMOUNT CLAIMS PAID 15 372.58 94 2,254.23 CLAIM ADJUSTMENTS 0 0.00 0 0.00 CLAIMS INTEREST 0.00 0.00 TOTAL CLAIMS PAYMENTS 15 372.58 94 2,254.23 CLAIMS DEFIED 3 6 CLAIMS IN PROCESS 0 0 -----------EARNINGS DATA----------- PAYMENTS: ---------- PAY`TENTS: IC CLAIMS PAYMENTS 372.58 2,254.23 SYSTEM PAYOUTS (NON-CLAIM SPECIFIC) 186,603.32 186,603.31 ACCOUNTS RECEIVABLE (OFFSETS): CLAIM SPECIFIC: CURRENT CYCLE 0.00 0.00 OUTSTANDING FROM PREVIOUS CYCLES 0.00 0.00 NON-CLAIM SPECIFIC OFFSETS 0.00 0.00 REPAYMENT AGREEMENT RECOVERIES 0.00 0.00 NET PAYMENT 166,975.89 188,857.54 REFUNDS: CLAIM SPECIFIC PDo-USTI4ENT REFUNDS 0.00 0.00 NON-CLAIM SPECIFIC REFUND'S 0.00 0.00 OTHER FINAI4CIAL: MANUAL PAYOUTS (NON-CLAIM SPECIFIC) 0.00 0.00 VOIDS 0.00 0.00 NET EARNINGS 186,97.5.89 158,857.54