HomeMy WebLinkAboutResolution - 206 - Agreement - Texas Tech School Of Medicine - Family Planning Services - 07_12_1979RESO W6 - 7/12/79
RR4f1T TTTTOW
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK:
THAT the Mayor of the City of Lubbock BE and is hereby authorized and
directed to execute for and on behalf of the City of Lubbock an Agreement
between Texas Tech School of Medicine and the City of Lubbock for services
required in Contract PS-021-04-P-00, Family Planning, attached herewith which
shall be spread upon the minutes of the Council and as spread upon the minutes
of this Council shall constitute and be a part of this Resolution as if fully
copied herein in detail.
Passed by the City Council this 12th day of July 311979.
D WEST, MAYOR
ATTEST:
Ile-lyn Gaffg , City SecretlfrYAr
surer
APPROVED AS TO FORM:
-Q74 I C
C. Ross, Jr., City Attorney
7L)e'nKw:pewh#
DENZEL PE (FULL
Director of Public Services Admin.
TIED TO RESO 206 - 7/12/79
a TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER
5CHOOL OF MEDICINE/Deportment of Obstetrics G Gynecology
Q Lubbock, Texos 79400/(806)
AGREEMENT
BETWEEN
TEXAS TECH SCHOOL OF;MEDICINE
and
CITY OF LUBBOCK
To be effective the 1st day of September , 1979, between Texas Tech
University School of Medicine, acting by and through its Department of
Obstetrics and Gynecology, located in the City of Lubbock, Texas, acting
by and through its Health Department, hereinafter called "CLHD".
WHEREAS, the CLHD desires and agrees to be a subcontractor to TTUSM in
providing the applicable services required in Contract PS-021-04-P-00,
Family Planning, applicable to Title XX, between TTUSM and the Texas
Department of Human Resources, a copy of which is attached hereto as Attachment
A, and made a part of this contract.
NOW, THEREFORE, in consideration of the mutual promises herein contained
it is agreed that:
THE CLHD:
1. Agrees to comply with all provisions, laws, and other
requirements in Attachement A of this contract, and
specifically Sections II, III and IV.
2. Agrees to submit detailed statements of charges each
month developed in the format agreeable to TTUSM and
in keeping with the fee schedule in Attachment. -A of
this subcontract. CLHD understands and agrees to the deduction
of 25% for administrative surcharge costs to TTUSM before sub..-
mitting a net billed amount, Such costs include but are not
limited to transportation of specimens, drawing of samples,
billing service, etc.
3, Agrees to obtain within 90 days of signing this agreement
certification by the Texas Department of Human Resources, Title
XX as fiscal intermediary agent and'Family,Planning.-vendor,
After said certification has been received, CLHD agrees to
maintain such -,during the period of this contract,
THE TTUM,
1, Agrees to keep CLHD informed of any changes in the requirements
of Title.XX,
2. Agrees to ,veimhurse CLHD for one hundred percent (100%) of
the net billed amount submitted under the provisions of this
contract, including Attachment A.
3. Agrees to assure that all CLHD policies and rules, as related
to Family Planning Services, are strictly complied with.before
performing service,
Both parties, -agree that this contract may be cancelled at any time by mutual
consent or in any event it may be cancelled by either party by giving thirty
(30) days notice in writing to theother party.
This contract shall become effective immediately upon its execution and shall
terminate August 31, 1980.
IN WITNESS WHEREOF, the parties hereto have executed this agreement
as of the day and year first above written.
CITY OF LUBBOCK:
BY:
Dirk West, Mayor
AT EST:
Evelyn Gaff a, City Secret ry easurer
APPROVED AS TO FORM:
J hn C. Ross, JR., City Atto ne
APPROVED:
� �7u
Denzel Per full
Director o ublic rvices Admin.
TEXAS TECH UNIVERSITY
SCHOOL OF MEDICINE:
RICHARD LOCKWOOD, M.D.
ATTEST:
Secretary
' • ' +. Slaw of Ie:as
• Department of Public Welfare
Form 2034
April 1977
A
STATE OF TEXAS
COUNTY OF TRAVIS
TITLE XX
FAMILY PLANNING CONTRACT NO. PS-021-01t—F-0c�
The State Department of Public Welfare, hereinafter referred to as the Department, and
TF143) TrCH SCHOOL OF 1•CDICI";E
►tcreinafter referred to as the Contractor, which has been certified by the Department's Title XIX fiscal
intermediary agent as a Title XIX family planning vendor, do hereby make and enter into this contract,
which constitutes the entire agreement between the Contractor and the Department.
The Department is the single Texas state agency responsible for administering the public welfare program
under the Social Security Act. Federal law and regulations, as well as State law, in TEX. REV. CIV. STAT.
ANN. art. G)Sc § 402), permit and authorize the Department, subject to certain limitations, to enter
into agreements with public or private agencies for the purposes of providing social and/or other services for
the benefit of eligible individuals. Since the Contractor desires to provide services for the benefit of certain
eligible individuals, as described herein, the Department and the Contractor make this contract.
The parties hereto mutually agree:
A. The stopc of the services to be provided by the Contractor and/or subcontracting ageney(ies) under this
contract, is limited to those services listed in the Plan of Operation which is attached to this contract
and incorporated into this contract in its entirety by specific reference. Any change, modification, or
amendment thereto, must be tnade with the prior written approval of the Department except as
otherwise provided in this contract and any such change, modification, or amendment to such Plan of
Oper::tion is not effective until approved by the Department. Such original Plan of Operation together
with any approved amendment as maintained on file by the Department will be considered to be the
controlling instruments in case any disputes arise relative to the wording of any portion of such Plan of
Operation or amendment thereto.
B. Medical and social services under this contract are extended to income eligible individuals. Social
services tinder this contract are extended to current AFDC and SSI recipients. Services offered to current
AFDC recipients, current SSI recipients, and income eligible individuals must be fully integrated with
those offered ro patients not subsidized by the Department.
=CE_R7T1F1EDORRECT COPY
Form 2034
rago 2
C. The basis for payment for services rendered under this contract is indicated in the set fee schedule
included in the aforementioned Plan of Operation. Any Cartractor•initiated amendment to the fee
schedule is subject to prier written Department approval. The Department may revise the fee sch--rlule
by giving the Contractor written notice of such revision.
D. The Department, the Contractor and all subcontractors, if'sny, will carry out the requirements for the
provision of services as set forth in Chapter II, Title 45 of the Code of Federal Regulations, as amended,
will monitor and conduct fiscal and/or program audits at reasonable times and will provide consultative
and technical assistance for the continuous development of the services contemplated by this contract.
The Department shall have authority to monitor and conduct fiscal and/or program audits of both the
contractor and its subcontractor(s) to the extent of services provided .under the terms of this contract.*
On site visits as well as access at reasonable times to all books and records will be granted State or
Federal auditing agencies, representatives of the United States Department of Health, Education, and
`Welfare and/or the Department when it is deemed necessary by the Department for .purposes of
inspection, monitoring, auditing, or evaluating said materials.
E. This contract is subject to the availability of State and Federal funds and if such funds become
unavailable, or if the total amount of funds allocated for this contract should become depleted during
any budget period and the Department is unable to obtain additional funds for such purposes, then this
contract will be terminated.
In the event that the Contractor fails to provide services in accordance with the provisions of this
contract, the Department may, upon written notice of default to the Contractor, terminate the whole or
any part of this contract, and such termination shall not be an exclusive remedy but shall be in addition
to any other rights and remedies provided by law or under this contract.
my F-arthermdre, in the event that Federal or State lama or other require.- eais should be amended or
judicially interpreted so as to render continued fulfillment of this contract, on the part of either party,
substantially unreasonable or impossible, or if the parties should be unable to agree upon any
amendment which would therefore be needed to entble the substantial continuation of the services
corntemplated herein, then, and in that event, the parties shall be discharged from any ftirther
obligations created under the terms of this contract, except for the equitable settlement of the respective
accrued interests or obligations incurred up to the date of termination.
F. This contract may be cancelled by mutual consent; however, if such mutual consent cannot be attained,
then, and in that event, either party to this contract may consider it to be cancelled by the giving of
thirty (30) days notice in writing to the other party and this contract shall thereupon be cancelled upon
the expiration of such thirty (30) day period.
G. This contract may be renewed and extended by written notice to the Contractor in the form of an
amendment from the Department; such amendment shall state the term and any conditions under
which the contract is to be renewed and extended, and each of such amendments of renewal shall be
incorporated into and become a part of this contract.
CERTIFIED AS CORRECT COPY
Form 2034
Page 3
P1
Ill.
The Contractor agrees to, and will require its sttbcontractor(s) if any, to agree to:
A. Ptovidc services in accordance with the aforementioned Plan of Operation and allow the Department to
monitor same.
B. Provide to the Department, in accordance with the procedures prescribed by the Department, a verified
and Proper monthly statement of charges, or certifcatinn of expenditures, for services which have been
rendered under this contract.
C. Refrain from entering into any subcontract(s) for services without prior approval or waiver of the right
of approval to subcontract.
All subcon:racts, if any, entered into, by the Contractor shall he written. Any subcontract entered into
by the Contractor shall be subject to the requirements of Title XX of the Social Security Act, as
amended, and of this contract. The Contractor agrees that it shall be responsible to the Department for
the performance of any subcontractor.
D. Comply with all applicable State licensing requirements and/or Federal certification requirements.
E. Furnish the Department with various statistical reports as required by the Department in the format
prescribed by the Department.
F. Make available at remonablc times and for reasonable periods those client records, books, and
supporting documents kept current by the Contractor and its subcontractor(s) pertaining to provided
services for purposes of inspection, monitoring, auditing, or evaluating by -Department personnel or
their representatives.
G. Pcrti6patc fully in any evaluation study of this program authorized by the Department.
H. Comply with Department rules and regulations pertaining to hearings concerning applicants for and
recipients of services and to abide by the decisions rendered by the Department in such hearings. The
Contractor shall inform all individuals of their right to such fair hearing.
1. Comply with the Federal Civil Rights Act of 1964, as amended, and TEX. REV. CIV. STAT. ANN.
art. 6252.16, as amended, and Executive Order No. 11246. entitled "Equal Employment Opportunity"
as supplemented in 41 C.F.R. Part 60, including but not limited to, giving equal opportunity both to
those seeking employment and those seeking services without regard to age, race, color, religion, sex, or
national origin.
J. Establish a method to secure the confidentiality of records and other information relating to clients it.
accordance with the applicable Federal law. rules, and regulations, as well as the applicable State law and
regulations.
K. Maintain and retain case information concerning those individuals and families who received services
and supporting fiscal documents adequate to ensure that claims for Federal matching funds are in accord
with applicable Federal requirements. Said documents shall be miintained and retained by the
Contractor and all subcontractors, if any, for a period of three (3) years after the date of submission of
the last expenditure report, or until an audit has been concluded, whichever is greater.
CERTIFIED AS CORRECT COPY
Form 2034
Page *4
L. Be primarily responsible for any audit exception or other payment deficiency in the program covered by
this contract which is found to exist after monitoring of auditing by the Department or the United
States Department of Health, Education, and Welfare, and be primarily responsible for the collection
and proper reimbursement to the Department of any amount paid in excess of the proper billing
amount. 1.
M. Submit billings and statistical documentation as required by the Department by the forty-fifth (45th)
day following the last day of the month in which a service was performed, and in any event, no later
than the ninetieth (90th) day following the last day of the month in which service was provided.
Failure to do so will be considered failure to comply with the contract. Such failure to comply is valid
justification for immediate termination of this contract.
N. Offer family planning sevices without regard to maternity, marital status, parenthood, or age; with
respect for the dignity of the individual; upon referral from any source including the patient's own
application; on a voluntary basis, ensuring the patient complete choice of provider and choice of
contraceptive method which is medically feasible. Patients may accept or reject contraceptive services
and supplies under this program with complete fregdom from coercion or pressure of mind and
conscience.
O. Use money received through the planned reimbursement mechanism specifically for family planning
services.
P. Accept reimbursement from the Department up to the maximum amount allowed by the Department as
set forth in the Plan of Operation as payment in full for services listed in the Plan of Operationi rendered
to individuals eligible under this contract, and to make no charge to the patient, any member of his
1q family, or to any other source excepting insurance companies for such services.
The Contractor may accept reimbursement from insurance companies, -provided that any such
reimbursement received from an insurance company shall be deducted from the amount to be
reimbursed by the Department. The Contractor further agrees to secure agreements to ensure that all
physicians and any others participating in the Contractor's family planning program make no additional
charge to any source other than to the Contractor for covered services rendered to persons eligible under
this contract for such services.
Attempt to serve an increasing number of those estimated to be eligible individuals in the area serv;d
by the agency, through such conveniences as outreach services, child care services, night and weekend
clinics, etc.
R. Abide by Department program guidelines as the Department develops them for purposes of clarifying,
expanding, and improving family planning services.
S. Determine eligibility of individuals according to policies and procedures promulgated by the
Department as set forth in the Plan of Operation.
CERTIFIED AS CORRECT COPY
.. i .
Form 2034
Pape 5
This Article IV is:
0 Applicable
IV.
❑ Inapplicable
The Contractor further agrees:
A. To provide the Department with detailed statements of charges each month developed in the format
rrrscribed by the Departrncrtt, and to promptly forward such bill to the Department along with a
•stattment certifying that the Contractor has provided each and every service for which billing is
rendered.
B. That funds certified by the Contractor for matching purposes in accordance with the terms of this
contract, will be funds which can be used to match Federal funds under the Social Security Act and
appropriate Federal rules and regulations. Records will be maintained to verify the source and amount
of funds certified by the Contractor for matching 'purposes for a period of three (3) years after
submission of the certification statement, or until an audit has been concluded, whichever is greater.
C. That to reimburse the Department for administrative and other operational costs incurred in procuring
federal funds, the Department shall be entitled to retain from any allowable reimbursement due the
Contractor an amount equal to zero percent ( 0 M of the total amount
certified to the Department as having been expended.
V.
The Department agrees to:
A. Pay the Contractor_23 c (percent) of the approved monthly b llinns for services which have been
rendered in accordance with the terms of this contract and its attached set fee schedule.
B. Recognize the fiscal policies and procedures of the Contractor and its subcontractor(s), if any, except
where rhey are in conflict with Federal and/or Stitt law, policies, rules, and regulations.
C. Perform such evaluation studies that the Department determines to be necessary and report to the
appropriate offiiers of the Ccntractor and its sabconttactor(s), if any, the preliminary results of the
study before the evaluation is concluded and the findings made a matter of record.
For the faithful perform ince of the terms of this contract, the parties hereto in their capacities as stated, affix
their signatures and bind themselves effective the first day of September
19_?8, and conti::uiug until Se: 1 t; bCr 1, 19 79 .
STATE DEPARTMENT OF PUBLIC WELFARE
Commissioner
uc
CERTIFIED AS CORRECT COPY.
Tr; US TECH 3CI10OL OF MMICIP:E
Abency IN ame
Vice PrPair3Nnr fo th—Se4enzeS Centers
Title
State of Texas
Department of Public Welfare
Form 2028
April 1977
TO:
CONTRACT TRANSN11TTAL
Lewis Mondy, Ph.D.
Program Manager
Family Planning & Family
Services Division
Social Services Branch
State Office 528-0
Date: August 7, 1978
FROM:
11athan Martin
Regional Administrator
Region # 021
Lubbock , Texas
IMail Code— 17"
Region x 021 is requesting the Commissioner's signature on the attached
purchase of social services contract between the Department of Public Welfare
(DPW) and Texas Tech University School of Medicine for the purchase
of Fmnily Planning Services as authorized by the Title XX
Comprehensive Annual Services Program Plan for Texas and the Legislative
Appropriations Request for this biennium.
Zw The undersigned certify that the proposed contract meet the standards and
regulations of DPW and the Federal government.
Re'ronal Administrator r Regional llirector for gocial
Nathan Martin Services
Fr Seale
Regional Director for Education Assistant Regional Administrator
(Training Contracts) _-
Carrol Crum
Attachments
�f CERTIFIED AS CORRECT COPY
lid �
a®
0
FORM 2028
Page 3
Needs Identification/Assessment
I hereby certify that:
1. No other DPW or community resource is available or sufficient to meet the
clients' need for this service.
2. There exists sufficient .potential benci•it to the clients to justify the purchase
of services.
3. The proposed contract can provide the resourcc required to meet the
identified need and to measurably benefit the clients.
4. The Federal, State, -and/or local funds required for the purchase of this
service have been identified and are available for use in purchasing this
service.
Program Director,
�. social Services
Si nature Title Date
Linda Flippen
Purchasability
I hereby certify that:
1. The service to be provided under the terms of this contract is purchasable
under 45 C.F.R. § 228 and the Comprehensive Annual Services Program flan
for Texas (CASPP).
2. The clients to whom the service is to be provided under this contract will be
selected from only those client groups authorized to receive this service
under 45 C.F.R. § 228 and the CASPP.
3. The proposed contract complies with the standards, limitations, and
priorities set by the Board of Public Welfare.
.� Program Director,
> �.1� �! r f_,r r Contract Services -7,:3
Signature Titic Date
Carob A. Lindemann
f„ CERTIFi�C,�,A'S:CO'RRECT COPY
4
l% �
Texas Department
cl Human fieiources
• Contract No.
�021-04-P-oo
SECTION 1 -Prime Contractor Data
INFORMA'I ION SHEET
PURCHASE OF SERVICE CONTRACT
Form 2(
July IS
Region No. County No.
02 152 .
Legal Name
®Contract Effective Date
Texas Tech University School
of Medicine
I 09-01-77
Commonly Used Name (if different from above)
\ Contract Termination Date
P 08-31-79
Address
ephone No.
P.O. Box 4269 Texas Tech Universit , Lubbock 79409
806/743-2340
Person Authorized to Sign Contract
Title
Type of Ownership (Cbeck one)
Richard A. Lockwood
VP for Health Science Centers
®Public ❑Private
Charter No,
Employer I.D. No.
Contact Person
Telephone No.
75-600-2622
Jon Bernier Exec. Director
806/743-2340
SECTION 11 - Summary of Payment
EFFECTIVE PAYMENT DATES BUDGET NAME BUDGET UNIT NUMBER MAXIMUM
NUMBER I RATE IELIG. UNITS REIMBURSABLE
Less fees from eligible clients (unit rate payment only) -
Total Regional Allocation for this contract
SECTION III - Funding
LOCAL FUNDS CONTRACT
$ 9500 Matching $ 9,500
-0 . administrative Overhead
$ 9500 Total Local Fund
State Funds - 0 -
CERTIFif"-b Aft qqa�RECT COPY
` •a;t+ Federal Funds 85,500
Contract Total $ 95,000
Form 2(
Page 2 of 2
ACTION IV — Service and/or Subcontractor Data (complete a separate sheet (SECTION III) for each different service or for each different
subcontract)
Program Activity Name Code
Family Planning 591
Service Activity Name Code
Social b Educational Family Planning 16F., 16Y
Name of Subcontracting Agency if applicable
Name of Contact Person
Address of Subcontracting Agency Telephone No.
1, Client categories to be served (check all applicable):
®Current AFDC ®Other Income Eligible
®Current SS ❑Without Regard to Income
®MAO Income Eligible ❑Ineligible
2. Total Number of Clients to be Served; ..$Z9 .PKQgl;alp •Deseri Rttion Page 1 ❑ per day
3. Number of Eligible Clients to be Served: ❑ per day
❑ per week
❑ per week
4. Unit of Service: ...................................................................
5. Number of Units of Service to All Clients: .................................................
6. Number of Units of Service to Eligible Clients: .................... ........................ _
I A- 7. B. (Complete only if service is children's day care)
® per mom
❑ per mom
Fee Schedu.
ADDRESSIES) OF
PROVIDING FACILITYDES)
HOURS OF
OPERATION
NUMBER OF CHILDREN IN EACH AGE GROUP
0-2 YRS.
3.5 YRS.
6.14 YRS.
0-5 YRS.
0.14 YRS.
0.17 YRS,
See -Attached List
TOTALS
8. Geographic Area Served:^
9. Goals (check all applicable):
a I EsII
Mentally, Physically, or Emotionally Handicapped
ee Attached List
FSIII E21V EX
Source of Federal Funds (check all applicable):
-CUXX ❑IV•B
N/A
11. Basis of Payment (check one):
❑WTFixed Unit Rate of .................. ....... S ��TTrerr�pr! C nf4F7FCT COPY
��-r G' r
OCost Reimbursement
17 Fundinnt
TOTAL AMOUNT OF
STATE FUNDS
S
MATCH AMOUNT OF
LOCAL FUNDS
9,500
TOTAL AMOUNT OF
F DERALFUNDS
85,000
G
AND TOTAL
S , 95,000
C!:,rtract No. 021-04—P--00
.;f f cc tive: 9-1-76
np
P.'i� 1 Form 2040
of ms'n. ) riP:,OU:1. April 1979
F .M!L FLNIJNILNG CON1•1"'"ACT PROGRAM DESCRIPTION
I. fso::ls
1'urst :tiff t►T tAX rn:illdatc of PL 93•6.17, the Fan-,ily Planni,tg Program defined
!•; the cirrus 4f t:11;. dl.scument shall operat: toward the achievement of -the
foilov: ing po.:11:
A. .°.hictii:s c,r n,^int.:ining cconotnl-; self-supporr to prevent, reduce, or
clir.:i:i.::: dt'Z•CTtfdi:ncl'.
S, ;;ii,ictinc or Tn.:intsintn}; scJ •suf{1ciency, rtiClUding reduction ar prcvcn-
tic!:► of dchcn�cnCy.
C. Preventing or remedying; n^.e'!ect, ahuse, car exploitation of children and
adults unable to protect their own intcrests, or preserving, rehabilitating,
or reuniting families.
11. Objective!.- and Measures
A. To uF•er seJAI and educa rurnal family plannin- services to 120_cur-
rera rcc ipicnts of AFDC, SDI, and MAO within the contract period.
B. To offer social and educadonal family planning services to
12L2—income eligible persons within the contract period.
C. To oficr medical (--tr--ily panning-crviccs tcincome tlicible
pc. -sons within the contract ; Lriod.
D. Idea sure. The nu:: bcr of current recipients and incorr,e eligible persons
who roc-;ive f: mily planning services within the contract ;period.
M. S^rvi:.c- to Coverer!
A. Ofrcc or Clinic Visits (Physician Directed)
The Department will provide reimbursement for the following services
and procedures whin prescribed, furnished, directed, or supervised by a
physiciati.
1. Cumplece licalth History and Physical Examination (Code 01) to
consist of:
a. Complete obstetric and gynecologic history (including.
menarche, menstrual, gravidity, parity, pregnancy outcomes,
and complications of pregnancy/delivery).
CERTIFIED AS CORRECT COPY
ConLrac .. ;lo. J'21—:14-eP—W
337
I_.ffcctive: ?-1-73
Page 2
Form 2040
Pr)r 2
b. History ut sionilica:rt hospitalization, and
F:cv:0VS t.:c:.ii;.al gars, in.la.Jing 1• rcicul tly inforniati—n about
throj,;I,.rvmvl llic dassca-w, l::'rall? C:'fl:ll diSv,.!w, hrcast and
;:enir�l nri.l t.an�, dialn:tic and ptCdiabctic conditions,
ceplt::lo,ia ailed migraine, hcmatolragic phcnnn-wna., pelvic
inflataar:,:y ttisease, visual :Nsturl_anccs, and mental depression.
c. liistoty of problems relitinti to prcvious contraceptive use.
d. Family, =ci:.l, physical, zt;d mensal hcaltli history.
c. Physical examination. Re.,omirlended I-roccdures for examina-
(ion shoul:! include, but are not limit.-d to:
a. Thyroid palpation
b. Examination of breasts and axillary glands
e. Ausculation of heart and lungs
d. Blood pressure
e. `:'cight and height
f. Abdominal cxamination
f.. Pelvic examination
h. Examination of extremities
f. Patient comu!atiun. Consul:atior includes:
a. Irl:truction of reprorluctivc anatomy and physiology.
b. Overview of available• rn,thods of contracepEion including;
consultation on the use of a natural fannily planning or
rhythm incrhod if chosen by the patient.
g. Duration or frequrncv
Their is a limit of unc annUal co niprchensive examination and
evaluation for each eligible patient per State fiscal year (Sep-
crnibcr I thruuz;h Aug
ust 31),-ercrpting; that a second rnm-
pmlictu Ave examination may be provided where a user of a
teurjl)c:r.try contraceptivc method elects surgical sterilization, in
which .:isc s scctrnd cornprelicnsive examination may be billed.
2. Fulluu•-up Visits
a. There may be follow-up visits (Code 02) or examinations
v.-hen necessary including home visits as required.
b. A medical hunts visit (Cock 3-1) is one made in response to an
acute incilital circumstance, requiring a medically -trained Pro-
fcssional. It must be cr.ndr:ctcd under the standing orders of a
physician.
CERTIFIED AS CORRECT COPY
1:
L1'fccLLvc: 9-1-7,;
3
ram 2oa)
Prian 3
-
B. I :aburat-my Services
1. The foll!r wins I. botatury scrv<<es arc reimbursable as routine pro.
ccdures
coveted under farnily planning services:
Z.
Hematucrit (Cade 03) and/or hern.ngiobin (Code 04)
b.
Urinalysis (for'supar and protein) (Code 05)
C.
Papa ni,:alaou smear (including cervical and vaginal) (Code 06)
d.
Misccllanevus culture or smear for gonorrhea •(if indicated)
(Code 07)
C.
Syphilis seruluuy (if indicated) (Code 08)
f.
Bacteria smear (v.g., bacterial study for Triehonnoniasis,
Manilla infection, etc.) (Code 09)
1;.
Triglyccrides fasting level confirmation test for patients 40
years of ale and over (Code 55).
al.
SNI1.12 Ic•vel cmifirm�,tirm test for patiems 40 years of
rage and ov,r %oilc 6).
2. The special lab.itatnry services and procedures noted below: wilt be
t:UYL'red
if t:c c.i; -1 as a result of positive history or if de cmcd
medically necessary at the time of examination:
_.
Tuberculu5is slain test (Code 10)
b.
(Microscopic art alysis or culture of urine (Code 11)
C.
Sickle cell screening (Code 12)
d.
Postprandial :Mood glucose (blood sugar) (Code 1 3)
C.
Rubella herta,lutination test (antibody screen) (Code 14)
f.
Pregnancy tcstin (Code_ 15)
g.
Blood tyke and/or Rh factor determination (Code 45)
h.
Triglyccridcs f.v.ting level confirmation test for patients over
40 yta! ; of a}•c (Co'le 55),
i.
ShIA-12 fasting level confirmation test for patients over 40
years of ai;e (Code 56).
CERTWIED AS CORRECT CGPY
v }
t. I'd 1. tr. 1 V.) • 'J•-1 �!I{'--r �l.'V
• Effective: 9-1-78
Page 4
Form 2040 ,
• Pape 4
3: Duration or r-mquency
a. In c.+uncction with the aimual cxannina !ion and cvaluatiori, the
ptucedurrs listcd as rou:inc •ill be covered immediately.
b. Ad,litional laboratory procedures nosed as special will be
coNercd if indicated as the result of rnsitive history or if
ticcnicd nictlically necessary at the tinie of examination by the
;�ttertciin- p::ycician or mcciical director in charge.
C. The follow-up visits and subsequent laboratory procedures will
be covered if deemed necessary by the attending physician or
medical director and if considcred an integral part of family
f-lanning services.
d. These services and procedures must be provided in the context
of medical judgment using policies and practices that con-
stitutc high quality family planning services.
C. Contraceptive Methods and Devices.
Iicimlaursement will be made by DHR for these services:
1. Vasectomy (Code 1 7) -- Components covered by this fee include
physician services, procedure room, equipment, supplies, anesthesia, ; =y
one sperm count, and tissue analysis. If performed in a -free-standing
facility, :,ny subsequent hospital charges must be billed to Code 4=1,
Treatment of Complications. If performed in a hospital-eonnccred
facility, the only spt-cific hospital charges allowed arc for Code 53,
Post-Op,r..tivc In -Patient Hospital Carc, except hospital charges for
complications which must b; billed to Code 44, Treatment of Com-
plications. Sterilization claims must be accompanied by a written
infurmcd*con,:nt document and must comply with Federal steriliza
tiun tegulstions (.15 C.F.R 205.35).
Vuiu=ry female sterilization.
a. non -therapeutic hysterectomy (Code 31) - The
singic surgical component covered by this fee is that of the pri-
niary physician. Hospital charges must be billed to Code 00,
Co niplete In-Paticnt Hospital Care, except hospital charges for
complication which must be billed to Code 44, Treatment of
Complications. Sterilization c1tims must be accompanied by a
written informed consent document and must comply with
Fcdcrjl stcrilization rcgulations (45 C.F.R. 205.35).
CERTIFIED AS CORRECT COPY
1.�..:Ll i.lL 1. lc•J. :Jyll,i!{•—r^l:'V
Effective: 9-1-78
Page 4. . -
Form 2040
Pape 4
C%
3. Duration or Ftcquenty
a. In counectiun with the janual examinatior- and t-aluation, the
procedures lists:; as rou-inc will be covered immediately.
b. Additional laboratory rrocedures noted as special will be
cc>cctcd if indicated as the result of positive history or if
decried medically necessary at the time of examination by the
attendin- r::ytician or medical director in charge.
C. The follow-up visits and subsequent laboratory procedures will
be covered if deem:•d necessary by the attending physician or
medical director and if considered an integral part of family
r•lanning services.
d. These services and procedures must be provided in the context
of medical judgment using policies and practices that con
stitutc high quality family planning services.
C. Contraceptive Methods and Devices.
Reimbursement will be made by MIR for these services:
1. Vasectomy (Code 17) — Components covered by this fee include
physician services, procedure room, equipment, supplies, anesthesia,
one spear count, and tissue analysis. If performed in a -free-standing
facility, ,,ny subsequent hospital charges must be billcd to Code 44,
Tre mment of Complications. If rerformcd in a hospital -connected
facility, the only specific hospital charges allowed arc for Code 53,
Post-Op.r.:tive in-l'atient Hospital Care, cxcept hospital charges for
complications which must b: bil!ed to Code 44, Treatment of Com-
plirstions. Stcrilization claims must b: accompanied by a written
iniorrncd•consent document and must comply with Federal steriliza
tiun tegtslations (45 C.F.R 205.35).
2. Voluntary female sterilization.
a Mcctire non -therapeutic hystcrectom (Code 31) — The
y
singly surgical component covered by this fee is that of the pri-
mary physician. lit)srital charges must be billed to Code 00,
Corirlete In-l'atient Hospital Care, except hospital charges for
complication which must be billed to Code 44, Treatment of
Complications. Sterilization claims must be accompanicd by a
written informed consent document and must comply with
Federal sterilization regulations (45 C.F.R. 205.35).
CERTIFIED AS CORRECT COPY
l- -