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HCA Special Terms and Conditions <br /> 1. Definitions Specific to Interagency Agreement. The words and phrases listed below, as used in this <br /> Interagency Agreement, shall each have the following definitions: <br /> "Contractor" means a ground emergency medical transport provider owned or operated by the state, city, <br /> county, fire protection district, community services district, health care district, federally recognized Indian <br /> tribe, or any unit of government defined under 42 C.F.R. Sec. 433.50. <br /> "Health Care Authority" or "HCA" means the agency designated by the Washington Legislature as the <br /> Single State Agency that oversees Washington State's medical assistance programs, including Medicaid, <br /> its employees and authorized agents. <br /> "Intergovernmental Transfer" or "IGT" or "MPG" means the guide detailing billing instructions on how <br /> a provider bills for health care-related services, equipment, and supplies provided to Medicaid-eligible <br /> clients. The guide is located at http://hca.wa.gov/billers-providers/claims-and-billing/professional-rates- <br /> and-billing-quides. <br /> "ProviderOne" means the Washington State consolidated single payment system for Medicaid, medical <br /> and similar health care provider claims. <br /> "Ground Emergency Medical Transport (GEMT) Program" allows qualified providers to receive <br /> supplemental payments for emergency ground ambulance transportation of Medicaid clients. <br /> "Local Matching Funds" means funds provided by the Contractor that: <br /> • Are derived from local tax based dollars; and <br /> • Are not local funds already being used as match for other federal programs, and meets <br /> applicable federal matching fund regulations. <br /> 2. Purpose. The purpose of this Agreement is to establish an Intergovernmental Transfer framework for <br /> HCA to reimburse the Contractor for providing covered GEMT services to Medicaid clients. <br /> 3. Statement of Work. The Contractor shall provide the services and do all things necessary for or <br /> incidental to the performance of work as set forth in Exhibit A, Statement of Work. <br /> 4. Monitoring. The Contractor must participate in the program monitoring process. HCA monitors GEMT <br /> services to assure compliance with agency policies, administrative codes, and definitions, OMB Circular A- <br /> 87, and Medicare Provider Reimbursement Manual Pub. 15.1. <br /> 5. Consideration. Solely for continued provision of GEMT Services by means of an Intergovernmental <br /> Transfer (IGT) arrangement, under the arrangement, the GEMT provider shall provide all of the nonfederal <br /> funds required for receipt of federal Medicaid funding for the service. <br /> a. Funding Stipulations. <br /> (1) Local Matching Funds. The Contractor shall: <br /> (a) Use local matching funds as the State's share to claim Federal Financial Participation ("FFP"), <br /> if the local matching funds are appropriated directly to the State or local agency, or transferred <br /> from other government agencies (including Indian Tribes) to the State or local agency and are <br /> State of Washington Page 2 of 19 Contract No.K2850 <br /> Health Care Authority <br />