SINGLE CASE AGREEMENT(SCA)

Yvonne Joyner, QP, BS

Provider Relations Specialist

Network Operations

Chauncey Dameron, MBA

Provider Relations Specialist

Network Operations

If there is a member who needs a specific Medicaid or state funded service for a specific period of time and there is not a provider in the network available to provide the needed service a Single Case Agreement (SCA) can be requested.

The SCA is submitted by the provider along with the Electronic Funds Transfer Form (EFT), Trading Partner Agreement (TPA), current Copies of Certificates of Insurance (COI), copies of required licenses, W-9, copy of voided check or an official letter from the bank providing the account and routing numbers and a paper TAR if

the requested service must be authorized.

• Application is available in two formats: printable and web submission.• Downloadable format www.eastpointe.net Provider Manuals and Forms Forms Single Case Agreement .

• This format should be submitted via fax to 252-407-2450 or via secure email to networkoperations@eastpointe.net.

• Electronic submission format: www.eastpointe.net Provider Manuals and Forms Electronic Forms Single Case Agreement .

• When using this format, the required documents listed under Attachment B should be uploaded to the application under the section provided for additional documents.

• These documents are available on the Eastpointe website at www.eastpointe.net Provider Manuals and Forms Forms.

• You should be able to save them to your desktop and once complete, they can be attached to both the Downloadable and/or Electronic Form.

they can be attached to the formdesk form.

them to your desktop and once complete, they can be attached to the formdesk form.

Medical necessity must be determined for services requiring pre-authorization before the SCA can be approved.

Members should not be placed or receive services until the Single Case Agreement is approved.

Provider will not receive payment for services until the SCA is approved and set up in Alpha.

Provider Information:

Provider Legal Name: Click here to enter text.

DBA Name: Click here to enter text.

Federal Tax ID: Click here to enter text. Agency NPI#: Click here to enter text.

CEO/ Director Name: Click here to enter text.

SINGLE CASE AGREEMENT(Must select one)

Funding Source: ☐ Medicaid

☐ IPRS

Date of Request: (date you submit application to Eastpointe)

Section:1 (This information should be the same as the information in NC Tracks)

Sarah N. Stroud, CEO

Corporate Office: 514 East Main Street Post Office Box 369

Beulaville, N.C. 28518 Administration: 800-513-4002

Access to Care: 800-913-6109

Provider Type:

☐ Agency / Licensed Facility ☐ Licensed Independent Practitioner (LIP)-Solo

☐ CABHA ☐ ICF-IDD

☐ Hospital ☐ Facility only IDD, PRTF

Section: 2 (must select one)

Mailing Address: Click here to enter text.

City: Click here to enter text. State: Click here to enter text.

Zip + 4: (both zip and plus 4 required) Click here to enter

text.

County: Click here to enter text.

Telephone Number: Click here to enter text. Email: Click here to enter text.

Primary Clinical Contact: Click here to enter text.

Telephone Number: Click here to enter text. Email: Click here to enter text.

Are you working with a Care Coordinator on this case? ☐

Yes ☐ No

Coordinator’s name: Click or tap here to enter text.

Organization Legal Entity Type:

☐ C-Corp ☐ S-Corp ☐ Limited Liability Partnership(LLC)

☐ Sole Proprietorship ☐ Cooperative ☐ General Partnership

☐ For Profit ☐ Not for profit ☐ Government

Section: 3 (Must select One)

Section: 4 (Person to contact for billing questions)

Billing Information:5

Billing Contact:

Billing Address:

City: State: Zip: (both zip and plus 4 required) County:

Service Location:

Site Address:

City: State: Zip + 4: (both zip and plus 4 required) County:

NPI Number: Taxonomy Number:

List Service requested at this site for member (Include):

(Both service and billing code required for each service requested)

Service Description: (Can request more than one

service)

Billing Code: ( a code must be provided for each service

requested)

License type (if applicable):

Section: 5 (Location where service will be provided)

Client Information:

Full Client Name: Client Medicaid #:

Client DOB: Client Medicaid County of Origin: (if applicable)

(Must be one of the twelve counties in the Eastpointe catchment area)

Requested Service Begin Date: (begin date required. This date should not be prior to submission date)

Requested Service End Date (if known):

Section: 6 (One member per application)

Accreditation Organization:

Number of years Accredited: Accreditation Expiration Date:

OR

☐ We are not required to be Accredited for the services we provide.

Do you currently have a Contract with another LME-MCO? ☐ Yes ☐ No

☐ If yes, please list all LME-MCO’s:

Have you ever been sanctioned, placed on probation, and lost accreditation/certification.

Section: 7 (Responses required)

Section: 8Note: For all LIP’s whose NPI numbers you will be using for Outpatient Services please complete this section. Please use

Attachment A for additional LIP’s.

Licensed Clinician Information: (All requested information must be provided)

Legal Name:

Address:

City: State: Zip + 4 (both zip and plus 4 required)

Date of Birth: Social Security No.: Gender:

Felony/Misdemeanor or Investigation: (If yes please explain) ☐ Yes ☐ No

Professional Schools attended: Graduation:

License Type: License Number:

Date Issued: Expiration Date:

DEA Number: (if applicable) NPI number:

Taxonomy Number:

Do you currently have a Contract with another LME-MCO? ☐ Yes ☐ No

☐ If yes, please list all LME-MCO’s:

Please identify your Insurance Carrier(s):

Professional Liability: Name:

Telephone No.: Policy #:

Are there any claims? ☐ Yes ☐ No

Are there any current or unsettled claims? ☐Yes ☐ No

Are there any circumstances that may result in a claim?☐ Yes ☐ No

Are any of the policies cancelled? ☐ Yes ☐ No

Commercial General Liability Insurance: Name:

Telephone No.: Policy #:

Worker’s Compensation Insurance: Name:

Telephone No.: Policy #:

(Responses required)

Required Attachments: ( Attachment B )

1. Electronic Funds Transfer (EFT) Agreement – (please complete and sign)

2. Trading Partner Agreement (TPA)– (please complete and sign)

3. Copies of Certificate(s) of Insurance (COI) or Accord-25 or associated form.

4. Copies of required Licenses.

5. Request for Taxpayer Identification Number (W-9)

6. Copy of voided check or bank letter with account and routing number.

Section:11 (explanation required for all Yes responses)

(documents required when submitting the Single Case Agreement request)

Investigation and Sanction Attached Questions:

(1) Are there any actions or investigations against you/ any owner or QP in your organization, privileges, billing organizations or sanctions? ☐ Yes ☐ No (if yes please describe) Click here to enter text.

(1) Do you have any adverse actions been filed against you? This would include Medicaid, Medicare or other Insurances. ☐ Yes ☐ No(if yes please describe) Click here to enter text.

(1) Has anyone in your company who has an ownership, managerial, or clinical role, ever been sanctioned by any professional organization or government organization for violation of ethics, professional misconduct, unprofessional conduct, incompetence or negligence in any state or county? ☐ Yes ☐ No (if yes please describe) Click here to enter text.

(1) Are you aware of any circumstances that may result in such action? ☐ Yes ☐ No (if yes please describe) Click here to enter text.

(1) Have you ever had a contract canceled by another LME-MCO, Area Authority, and County Program in NC or a similar entity in another state? ☐ Yes ☐ No (if yes please describe) Click here to enter text.

(1) Please Provide a listing of shareholders/partners with 5% or more ownership AND officers, directors, managers, EFT authorizedindividuals. (See Attachment C).

Investigation and Sanction Attached Questions: (explanation required for all Yes responses)

(1) Are there any actions or investigations against you/ any owner or QP in your organization, privileges, billing organizations or sanctions?☐ Yes ☐ No (if yes please describe)

(2) Do you have any adverse actions been filed against you? This would include Medicaid, Medicare or other Insurances.☐ Yes ☐ No (if yes please describe)

(3) Has anyone in your company who has an ownership, managerial, or clinical role, ever been sanctioned by any professional organization or government organization for violation of ethics, professional misconduct, unprofessional conduct, incompetence or negligence in any state or county? ☐ Yes ☐ No (if yes please describe)

(4) Are you aware of any circumstances that may result in such action? ☐ Yes ☐ No (if yes please describe)

(5) Have you ever had a contract canceled by another LME-MCO, Area Authority, and County Program in NC or a similar entity in another state? ☐ Yes ☐ No (if yes please describe)

Please Provide a listing of shareholders/partners with 5% or more ownership AND officers, directors, managers, EFT authorizedindividuals. (See Attachment C).

Upon full execution of this Application/Agreement, the parties agree as follows:

1. Provider shall notify EASTPOINTE prior to the discharge of Client and shall allow designated EASTPOINTE staff to attend any discharge or treatment meetings regarding the Client served under this Agreement.

2. Provider warrants that it is in compliance with all applicable federal, state and local laws, rules and regulations, licensure and accreditation requirements governing the provision of services to Client at all times relevant to this Agreement.

3. EASTPOINTE reserves the right to refer enrollees to other providers, and no referrals or authorizations are guaranteed to take place under this Agreement.

4. Provider shall be responsible for completion and retention of all necessary and customary documentation required for the services provided under this Agreement. Provider agrees and understands that EASTPOINTE may inspect financial records concerning claims paid on behalf of Client, records of staff who delivered or supervised the delivery of paid services to Client, Client clinical records, and any other clinical or financial items related to the claims paid on behalf of Client deemed necessary to assure compliance with applicable state or federal laws, rules and regulations.

Provider shall provide copies of records or other information within timeframes

of written request from Eastpointe.

5. Provider warrants that it has and will continuously maintain insurance coverage

with a carrier authorized to do business in North Carolina, or maintain equivalent

coverage under a self-insurance program that is actuarially sound, meeting the

following coverage requirements:

a. Professional Liability: Professional Liability Insurance shall protect the

Provider and any employee performing work under this Agreement for an

amount of not less than $1,000,000.00 per occurrence and proof of coverage at

or exceeding $3,000,000.00 in the annual aggregate.

b. Comprehensive General Liability: Bodily Injury and Property Damage

Liability Insurance shall protect the Provider and any employee performing

work under this Agreement from claims of Bodily Injury or Property Damage,

which may arise from operations under the Contract. The amounts of such

insurance shall not be less than $1,000,000.00 per Occurrence/$3,000,000.00

per Aggregate/ $1,000,000.00 Personal and Advertising Injury/$50,000.00 Fire

Damage. The policy shall not include exclusion for contractual liability.

c. Workers’ Compensation and Occupational Disease Insurance: Provider

shall maintain workers’ compensation and occupational disease insurance as

required by the statutory requirements of the State of North Carolina.

6. For some purposes of the Agreement (other than treatment purposes) the PROVIDER may be considered a “Business Associate” of the LME/MCO as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and as such will comply with all applicable HIPAA regulations for Business Associates as further expanded by the Health Information Technology for Economic and Clinical Health Act (HITECH Act), which was adopted as part of the American Recovery and Reinvestment Act of 2009, commonly known as “ARRA” (Public Law 111-5). Pursuant to Controlling Authority, specifically 45 C.F.R. § 164.506, PROVIDER and LME/MCO may share an Enrollee’s protected health information (“PHI”) for the purposes of treatment, payment, or health care operations without the Enrollee’s consent.7. All claims must be submitted electronically either through HIPAA Compliant Transaction Sets 820 – Premium Payment, 834 – Member Enrollment and Eligibility Maintenance, 835 – Remittance Advice, 837P – Professional claims, 837I –Institutional claims, or the EASTPOINTE secure web based billing system.

8. Provider understands and agrees that claims for services must be submitted within ninety (90) days of the date of service or discharge (whichever is later), except that Provider may submit claims subsequent to the ninety (90) day limit in instances where the Client has been retroactively enrolled with Medicaid or EASTPOINTE, or where the Client has primary insurance which has not yet paid or denied its claim. In such instances, Provider may bill EASTPOINTE within ninety (90) days of receipt of notice by the Provider of the Client’s eligibility for Medicaid, or within 90 days of final action (including payment or denial) by the primary insurance or Medicare (whichever is later).9. EASTPOINTE agrees to reimburse Provider for approved Clean Claims for covered services for the Client named herein within thirty days of the date of receipt. Within eighteen (18) days after EASTPOINTE receives a claim from Provider, EASTPOINTE shall either: (1) approve payment of the claim, (2) deny payment of the claim, or (3) request additional information that is required for making an approval or denial.

Signatures:By signing below, Provider certifies that all of the information and attachments provided herein are true and

accurate to the best of their knowledge. Provider further understands that any false or misleading information

may be cause for denial or termination of any and all agreements or contracts with EASTPOINTE. Provider

understands submission of the application does not guarantee the issuance of an agreement. Provider signifies

their willingness for EASTPOINTE to verify all information presented in this application and to provide

additional information to EASTPOINTE, if needed, to verify the accuracy of the information contained herein.

Provider agrees to provide any additional information at request of EASTPOINTE to verify information and

address issues of concern prior to the approval of the application.

IN WITNESS WHEREOF, each party has caused this agreement to be executed in multiple copies, each

of which shall be deemed an original, as the act of said party. Each individual signing below certifies that

he or she has been granted the authority to bind Provider to the terms of this Agreement and any

Addendums or Attachments thereto.

Enter Provider Name: _(Should be the same as the Provider Legal Name)____

Sign: __(Original signature required)______________________ Date: (Original date required)

Print Name: _______________________________________

Title: ____(required)______________________________

EASTPOINTE (Do not write on this page)

Address: 500 Nash Medical Arts Mall

Rocky Mount, NC 27804

Telephone: 1-888-977-2160

_____________________________________________ ____________________________

Sarah N. Stroud Date

Legally Authorized Representative

Chief Executive Officer

This instrument has been pre-audited in the manner required by the Local Government

Budget and Fiscal Control Act. General Statute 159

_____________________________________________ _____________________________

Catherine Dalton Date

Legally Authorized Representative

Chief of Business Operations

MCO Approved Begin Date: ____________________

MCO Approved End Date: ______________________

The request was processed on timeframe to match the service authorization request and was processed as:

MCO use only:

☐ Urgent

☐ Non-Urgent

Attachment A

(Continue from Section 8)

Licensed Clinician Information:(must be entirely completed if the below NPI number will be used when

submitting claims. Duplicate as needed)

Legal Name:

Address:

City: State: Zip + 4

Date of Birth: Social Security No.: Gender:

Felony/Misdemeanor or Investigation: (If yes please explain) ☐ Yes ☐ No

Professional Schools attended: Graduation:

License Type: License Number:

Date Issued: Expiration Date:

DEA Number: (if applicable) NPI number:

Taxonomy Number:

Accreditation Organization:

Number of years Accredited: Accreditation Expiration Date:

OR

☐ We are not required to be Accredited for the services we provide.

Do you currently have a Contract with another LME-MCO? ☐ Yes ☐ No

If yes, please list LME-MCO(s):

Attachment B

(Continue from Section 10)

Required Attachments:

1. Electronic Funds Transfer (EFT) Agreement – (please complete and sign)

2. Trading Partner Agreement – (please complete and sign)

3. Copies of Certificate(s) of Insurance (COI) or Accord-25 or associated form.

4. Copies of required Licenses.

5. Request for Taxpayer Identification Number (W-9)

6. Copy of voided check or bank letter with account and routing number.

Attachment C

(Continue from Section 11)

List their: Names: Click here to enter text.

Demographic information: Click here to enter text.

Social Security No.: Click here to enter text.

% of ownership and/or position: Click here to enter text.

List their: Names: Click here to enter text.

Demographic information: Click here to enter text.

Social Security No.: Click here to enter text.

% of ownership and/or position: Click here to enter text.

List their: Names: Click here to enter text.

Demographic information: Click here to enter text.

Social Security No.: Click here to enter text.

% of ownership and/or position: Click here to enter text.

List their: Names: Click here to enter text.

Demographic information: Click here to enter text.

Social Security No.: Click here to enter text.

% of ownership and/or position: Click here to enter text.

Please provide a listing of shareholders/partners with 5% or more ownership AND officers, Directors,

Managers, Electronic Funds Transfer (EFT) authorized individuals. (This information should be

provided for anyone with 5% ownership whether they work for the agency or not)

SCA PROCESS

Reminders:•This application is to be used when a member needs a specific Medicaid or state funded service for a specific period of time and there is not a provider in the network available to provide the needed service. • Application will not be processed if there is an in network provider available to provide the needed service.

• This application is used to request both Medicaid and IPRS funded services.

• All questions on the application must be answered.

• Only one member per application.

• Multiple services can be requested on the same application. Both the service and service code must be provided.

• Funding Source: Is the requested service Medicaid or IPRS Funded?

SCA PROCESSDate: actual date the application is submitted to Eastpointe.

Provider information on the application should be the same as the provider information in NC Tracks or the application will be determined Unable to Process (UTP).

Required attachments (Section 10) must be submitted along with SCA.

Zip codes require both the zip code and the plus 4.

COI must be current. Provider is responsible for sending updated COI to Eastpointe. Insurance requirements are listed on the application under #5 of the terms of the executed Single Case Agreement.

All applications require an original signature and signature date to prevent being determined Unable to Process.

Incomplete applications cannot be processed.

A secure email and certified UTP letter is sent to provider when an application cannot be processed.

It is the provider’s responsibility to resubmit the SCA with the required updates indicated in the UTP letter.

Resubmitted applications require an updated signature and signature date on all forms.

Providers are responsible for reviewing the approved SCA for the begin and end date to determine the term of the approved SCA.

Medical necessity must be determined for services requiring pre-authorization before the SCA can be approved.

Members should not be placed or receive services until the Single Case Agreement is approved.

Provider will not receive payment for services until the SCA is approved and set up in Alpha.

Questions regarding the SCA, review process, Unable to Process notification, etc., will be addressed by Network Operations.

Contact can be made via telephone at 888-977-2160 or by sending a secure email to networkoperations@eastpointe.net