Washington Apple Health 1/24/2018

Washington State Health Care uthority Washington Apple Health (Medicaid) Ground Emergency Medical Transportation (GEMT) Program Annual Provider Participation Agreement Name of provider: City of Everett Provider NPI number: 1770561706 Service period begin date: July 1, 2015 Service period end date: June 30, 2016 Statement of Intent The purpose of this agreement is to allow participation in the Ground Emergency Medical Transportation Supplemental Reimbursement Program (GEMT Program) by the governmentally owned or operated provider,named above,subject to the provider's compliance with the requirements and responsibilities set forth in this agreement. GEMT Provider Responsibilities By entering into this agreement,the provider agrees to the following: A. Provider agrees to comply with each the following,as periodically amended: • Title XIX of the Social Security Act • Titles 42 and 45 of the Code of Federal Regulations (CFR) • Washington State Medicaid State Plan • State issued policy directives,including the Revised Code of Washington,the Washington Administrative Code,Washington Apple Health Billing Guides • Terms of the provider's Medicaid Core Provider Agreement • Federal Office of Management and Budget(OMB) Circular A-87 B. Provider agrees to ensure all applicable state and federal requirements,as identified in paragraph A, above,are met in rendering services under this agreement.The provider understands and agrees that their failure to meet all applicable state and federal requirements in rendering services subject to supplemental reimbursement under this agreement shall be sufficient cause for the state to deny or recoup payments to the provider as well as terminate this agreement. C. Provider agrees to comply with the following expense allowability and fiscal documentation requirements: 1) Submit annually the participation agreement and cost report form. 2) Maintain for review and audit and supply to the state,upon request,auditable documentation of all amounts claimed,and any other records required by the federal Centers for Medicare and Medicaid Services (CMS),pursuant to this agreement to permit a determination of expense allowability(RCW 41.05.730). 3) If the allowability or appropriateness of an expense cannot be determined by the state because fiscal records or other documentation is not present or is inadequate,according to generally accepted accounting principles or practices,all questionable costs may be disallowed and payment maybe based solely on the current Medicaid fee schedule.Upon receipt of adequate documentation supporting a disallowed or questionable expense,supplemental payment reimbursement may resume. HCA 42-0002(11/17)