s.lcamc.net/images/board/09_26_2019_board_meeting_packet.pdf · financial~(lynn mcnitt, dr. carr,...

LAKE FORK HEALTH SERVICE DISTRICT BOARD OF DIRECTORS MONTHLY MEETING AGENDA

MISSION STATEMENT The mission ofthe Lake Fork Health Service District is to enhance the quality oflife in our community

by promoting weIness andproviding quality health services with care and compassion while exercising fIScal responsibility

Thursday September 26 2019 - Moseley Health Care Complex Zeller Wellness Center

I CALL TO ORDER~ Approximately 830AM II ROLLCALL III WORKSHOP

A Executive Director Report 1 Financial~(Lynn McNitt Dr Carr Jessica)~ Review June amp July 2019 financials 2 Business Development~(Jami Mike) 3 Community Relations~(Janel Jerry)shy4 Personnel- (Dr Carr Jessica Janel amp Jami) S Policy amp Procedure Review- Administrative- See attached 6 2020 Health Insurance Prices

B Presidents Report- Can we move the October board meeting to Thursday October 10th or 17th C Medical Director Report-D Dental Director Report E Any other items

IV MEETING AGENDA ITEMS A Consider any updates to the meeting agenda B Consider approval ofminutes from prior board meetings- 08222019 C Consider approval of revised administrative policy and procedures to include todays date as the

revised date for those policies which had amendments

V CITIZEN COMMENTS FROM THE FLOOR

VI ADJOURN

Times stated are approximate and the agenda may be modified as necessary at the discretion of the Board

LAKE FORK HEALTH SERVICE DISTRICT BOARD OF DIRECTORS-SPECIAL MEETING

Todays Date is Thursday August 22 2019 1 The regular monthly meeting of the Lake Fork Health Service District was called to order by Janel Warren at 900 AM

The meeting was held in the Moseley Health Care Complex

II Roll Call In attendance were board members Janel Warren Mike Schell Lynn McNitt and Jerry Johnson Jessica Whiddon Bernie Krystyniak Ashley Mines Nancy Zeller and Bruce Uchida were also present Malinda McDonald is the recording secretary

Board of Directors

President Janel Warren Vice-President Jami Scroggins Secretary Mike Schell Treasurer Lynn McNitt Board Member Jerry Johnson

III Workshop A Executive Director Report- Medical patient counts through June 2019 were 1364 vs

1595 through June 2018 A difference of 231 patients Dental patient counts through June 2019 were 353 versus 393 through June 2018 A difference of 40 patients

~ Business Development- None ~ Community Relations- Ad for Sunday closing October-April

~ Personnel- None

2 President Reports None

3 Medical Director Reports None

4 Dental Director- None

IV MEETING

A Consider any updates to the meeting agenda None

B Consider approval of Minutes from prior months board meeting

Motion Approval of Minutes for meeting-

Motion Jerry Johnson Second Mike Schell Vote All vote yes Motion Carries

V CITIZEN COMMENTS FROM FLOOR Nancy would like for the clinic to report to Kathy Moseley on how the clinic is doing to keep her informed

VI Adjourn Meeting is adjourned at 905 AM Next meeting will be September 26 2019 at approximately 830 am in the Zeller Wellness amp Education Center in the Mosley Health Care Complex

(President) Date

(Secretary) Date

(Recording Secretary) Date

Lake Fork Health Service District

Category Administrative 0f2 Policy Protection of Record Information on District Premises

Policy Number ADMIN-Ql

Effective Date 110109

Last Revised Date 119amp2915_

Reference 42CFR49110(b)(1)(3)-Protection of Record Information

Last Reviewed Date U182Q1+10l10l2018

Purpose 42CFR49110(b)(1)(3) requires this certified rural health clinic to maintain confidentiality of record information and provide safeguards against loss destruction or unauthorized use of patients medical record In addition the clinic must assure patients written consent for release of information not authorized by law

Statement of Policy lake Fork Health Service District shall maintain strict adherence to patient confidentially and shall maintain safeguards against loss destruction or unauthorized use of patients record

All staff contractors or volunteers with access to the clinic area will read and sign a statement agreeing to protection of patient privacy and records

All Clinic patient records history current conditions appointment status etc shall be kept confidential and shall only be discussed with members of the lake Fork Health Service District staff with a need to know

Release of medical information or medical records to outside entities without permission and out of compliance with these policies is cause for immediate dismissal ofthe employee

Procedure 1 Access to a patient medical record shall be restricted to levels of security clearance allowing

staff to view patients medical records on a need to know basis only At NO TIME shall anyone other than an employee or authorized individual of the clinic be allowed to gain access to any patient record or to any computerized records including patient scheduling

2 No information about any patient their appointment status (to anyone other than the patient or their guardian) or any reports about the patient (lab etc) shall be released without the expressed written consent of the patient or the patients parentguardian This release shall be on the form designed and approved by the clinic ONLY and shall be released to the individual provider or company listed on the form amptWr This form shall be kept in the patients record along with a memo detailing exactly what records and information were released

3 At the discretion of the BlIsiRess MaRager-Executive Director notarization of the signature on this or other forms may be required for release of any information

4 Staff members should be constantly aware of the possibility of having a confidential conversation overheard including telephone conversations Staff must insure confidentiality prior to such a conversation

5 Only employees and authorized volunteers of the District shall answer telephones for incoming calls The sliding glass windows should be closed during phone or staff conversations taking place in the front office

6 Only people who have read and signed a statement agreeing to protection of patient privacy and records are allowed in the front office Congregation in the front office should be avoided as much as possible (esp to discuss patient issues) Anyone discussing patient information in the front office hallways or other clinic areas must be aware of others present and the possibility of inadvertent disclosure of private information

7 Employees may not remove a medical record from the clinic

8 At no time shall patients health information be examinable by other patients in the patient care area To the extent that a patients medical chart is placed or held in an area visible to patients (Le nurse station exam room door) the charts shall be turned so that that the namepatient detail cannot be seen

Lake Fork Health Service District Category Administrative Page 1013 Policy Patient Consent Procedures and Authorization to ReleaseObtain Medical Information

Policy Number ADMIN~2


Last Revised Date 110S2Glamp


Last Reviewed Date Ill8(aOl~10l10l2018

Purpose 42CFR49110(b)(l)(3) requires this certified rural health clinic to maintain confidentiality of record information and provide safeguards against loss destruction or unauthorized use of patients medical record In addition the clinic must assure patients written consent for release of information not authorized by law

Statement of Policy The lake Fork Health Service District undertakes a legal and ethical responsibility to foster and preserve the privacy and confidentiality of patient information

There shall be strict adherence to the basic principle of prior consent by the patient required before information is released or disclosed or made available for review An exception may be when a specific law regulation or internal administrative need requires and permits such access without patient consent

Procedure

Responsibility for Release of Information

All requests for release of information andor access to patient care records for the facility shall be coordinated by the 811siRess MaRager Executive Director or as delegated so that uniform timely processing consistent with the specific legal and regulatory constraints associated with each type of request is achieved This comprehensive system involves the following functions

1 Apply the detailed provisions of specific laws and regulations 2 Honor the patients right to authorize or deny such release of information 3 Apply administrative processes to all requests

Release of Information

Requests for information from patient records shall be processed in a timely consistent manner

Priorities and Time Frames

The following priorities and time frames shall apply to release of information requests processed~ 811siReSS MaRager Providing information as soon as possible is our goal

1 Printed information from the medical record is requested 2 Priority requests pertaining to current care of patient within one working day

3 Patient request for access to own record within one working day of record completion 4 Subpoenas and depositions as required 5 All other requests within five working days

The BtisiAess Maflaer Executive Director as well as the appropriate health care provider(s) of the clinic shall be notified jf1Refl aflY oftRe folloNiflg osstlrs

1 PriflteEl iAfoFlflatioA is reqllesle8 from tRc meelieal resorEl 2 Patieflt or rel9resefltatit(e reqtlests Elireet aeeess to lRe meElisal reeorEl

~ lbegal action is initiated

Release ofInformation Process

Release of information by District personnel shall carry out the following procedures

1 Receive requests and determine their legitimacy

2 Review requests and determine that authorization requirements have been met

3 Initiate the necessary reply to those making requests if information will not be sent or if authorization is needed

4 Determine billable or non-billable status of requests

LDesignate priority assignments to requests

amp06 6 MaifllaiA tRe trackifl log afl819Foeess iflEjtliries eOASeFAifl tRe 5tatllS of reqllests A copy of

each release request will be scanned into and kept on file in the patients electronic medical records chart

7 Select the material to be released

8 Complete request

Authorization to Release Information

Capacity to Authorize Release ofInformation

1 The patient parent of minor or a duly authorized representative (eg lawyer guardian) proof of authorized representation is required

2 Deceased patient Next of kin as stated on the admission face sheet (relationship to be stated on authorization) or executor of estate

Content and Format of Authorization

Written authorization should contain detailed specific information directing the release of information Authorizations shall specifically include the following

1 Full name of the patient 2 Date of birth of the patient 3 last 4 digits of the patients social security number 4 Person or organizationcompany to whom the information is to be released 5 Purpose ofthe disclosure (eg support information for an insurance claim) signature ofthe

patient or duly authorized representative

6 Dated amp signed (date cannot precede the time period of the treatment dates for which information is to be released)

7 Information to be released (eg episode of care covered treatment andor procedures specific test results any and all available records - not to include records from another office)

8 The signature of a witness to the patients signature is optional but encouraged

Revocation ofAuthorization A patient or person with capacity to authorize release may revoke an authorization by providing a written statement to the clinic This revocation shall become effective when it is received by the clinic

Refusal to Honor Authorization Authorization shall not be honored in situations where there is reasonable doubt or question as to the

following

1 Identity of the person presenting the authorization 2 Status of the individual as the duly appointed representative of a minor deceased or

incompetent patient 3 Legal age or status as an emancipated minor 4 Patient capacity to understand the meaning of the authorization 5 Authenticity of the patient signature 6 Current validity of authorization

The Executive Director BlIsiAeSS MaAager or designee shall make determinations regarding validity of the authorization in cases where there is a question regarding appropriateness


Category Administrative Page lof2

Policy Health Care Records and Audits Policy Number ADMIN-03


Last Revised Date H071(~OH

Reference 42CFR49110(a)-Patient Records

Last Reviewed Date U~g~(~9a811l07l2018

I

I

Purpose 42CFR49110(a) requires this certified rural health clinic to maintain a clinical record system in accordance with written policies and procedures

Statement of Policy Designated professional staff are responsible for maintaining the records and for ensuring that they are completely and accurately documented readily accessible and systematically organized

Records of all minors will be maintained until the patient reaches the age of majoritgt JilhIS si)( years (18 + Records of adult patients will be kept on active status for seven years after the last visit at the clinic

The patient record for all patients ofthe clinic shall be all-inclusive for current past and remote care for each patient

Procedure 1 The receptionist patient records staff and other designated business office staff shall be

responsible for maintaining complete patient records on each patient within their job responsibilities

2 Staff members enter test results data and patient information (as they have been trained) into the EHR (electronic patient recordkeeping) system

3 The Provider shall review items entered by the staff expand that information where appropriate and complete any visit by completing the record and saving the document for signing Signing can be done electronically by approved individuals

4 All information and correspondence pertaining to the patient including old records will be recorded (ie scanned) into the appropriate electronic chart sections

5 All patient contact shall be recorded (Le phone portal WebViei messaging) in the EHR including responses made to that contact (ie phone portal WebView messaging)

6 The patients healthcare provider shall review entries by the nurse or assistant and use that review to respond or instruct (patient or staff)

7 Notes requiring prescription medications (refills or new) will be reviewed and electronically signed by the practitioner authorizing them

8 Drug samples provided to the patient shall be noted in the EHR prescription module with the notation sample

9 The clinic staff shall obtain patient records from other providers (consultants or prior physicians) prior to the Moseley Health Care Complex visit or when the provider indicates it is needed

10 laboratory X-Ray and Consultation reports shall be recorded in the appropriate sections of patients electronic chart

11 Chart audit (tpicallt te recorEis RloRth) will be done quarterly by the assigned nursing staff EillriRg weeki staff RleetiRgs The recorEi fer allEiit shalllle selecteEi by the 811siAeSS MaRager FaRaeRlI eR patieRts seeR EillriRg that qllarter

12 Any actionable critique done at the Chart Audit will be recorded in the file kept at the nurses stationStaff MeetiRg RliRlltes by the 811siReSS MaRager aAEi actieRscorrectieAs carrieEi ellt as assigAeaagreeEi

Lake Fork Health Service District Category Administrative Page lof2 Policy Contents of the Patient Record Policy Number ADMIN-04 Effective Date

110109 Last Revised Date

l1gSaglsect Reference 42CFR49110(a)(3)-Medical Records

Last Reviewed Date l1a~aglJ 12[05[2018

Purpose 42CFR 49110 requires this certified rural health clinic to maintain medical records that include as applicable 1) identification of social data evidence of consent forms pertinent medical history assessment of health status and healthcare needs of the patient and a brief history of the episode disposition and instructions to the patient 2) reports of physical examinations diagnostic and laboratory test results and consultative findings 3) all physicians orders reports oftreatments and medications and other pertinent information necessary to monitor the patients progress and 4) signatures of the physician or other healthcare professional

Statement of Policy The Lake Fork Health Service District shall maintain patient records in accordance with 42CFR49110(a)(3)

Each patient record for health care at the clinic shall include all legally required documents meeting or exceeding all Medicaid Medicare and other pertinent federal regulations

Procedure LThe contents of all health care recordHhaUmay include

a) Diagnostic test results b) Lab test results c) Progress notes d) Signed consent forms (updated annually) e) Medical records from previous providers if pertinent f) Detailed medical history g) Social data h) Patient identification i) Health assessments j) Discharge summaries k) Problem list I) Medication list m) Documentation of instructions to patients n) Orders written on nursing notes amp co-signed by provider 0) Summary of phone communications with patient p) Insurance information q) Immunization records r) Other appropriate information as required by RHC regulations third-party

resources etc s) A list of patient education items and documents that were provided

2 Records shall be filed in the applicable sections of the EHR (electronic recordkeeping system) (ie progress notes test reports) or dental record

3 Drug allergies for each patient shall be recorded and available in the EHR or dental record

4 FiliRg af JlatieRt retards is the resJlaRsibility af the FFeAt Otfiee Staff Th is tasl( is ta be Jlerfermed as saaR as the thart has beeR released By the cliRical staff ar at the eRa af eath aay

S The FraRt Office staff shall maiRtaiR arElerlt files aREI are resJlaRsiBle fer the geReral care af the files

46 The Front Office staff shall periodically purge old files to relocate or destroy inactive records in accordance with appropriate laws and regulations regarding file retention

Lake Fork Health Service District Category Administrative Page 10f 2 Policy New Patient Registration Policy Number ADMIN-OS Effective Date Last Revised Date Reference

110109 ugsectl~g1i 42CFR4917(b)(2)-Policies and Unes of Authority

Last Reviewed Date U~Ol~~ 12l05l2018

Purpose 42CFR4917(b)(2) requires that this organizations policies and lines of authority and responsibilities are clearly set forth in writing

Statement of Policy The Lake Fork Health Service District interprets 42CFR4917 (b)(2) to include administrative policies that cover topics including patient registration The District shall maintain an efficient process for new patient check-in to include demographic insurance consents and medical history information useful to provide care

Procedure 1 At the time a new patient schedules their first appointment the receptionist shall advise the

patient to bring the medications (in their bottles) they are currently taking (including supplements)

2 New patient will sign in at the reception desk and complete a New Patient Registration Packet

3 The new patient packet shall contain

a) Information Sheet (Contact information Past Medical History Family History Medications Allergies)

b) Consent Forms (CoFlseRt to Treat Qflality Health Netork Practice PartFleuror Research Netork)

c) Release of Information (if appropriate) d) Rights (HIPAA) e) Responsibilities

4 The receptionist shall confirm the forms have been completely and accurately filled out complete with all required signatures and shall create an electronic medical chart Pertinent insurance cards (Private Medicare Medicaid SupplementalSecondary) shall be scanned or photocopied along with all other pertinent cards and placed into the patients record (made available for the Biller)

5 Co-Pays shall be collected at the time of the visit If the commercial insurance card does not provide information on how much the patient must pay as their co-pay amount the receptionist shall call the insurance company prior to the patient leaving the clinic The receptionist must ask the insurance company the amount of the deductible for the patient and what amount of co-payor percentage of charges that is the responsibility of the patient Co-Pay amounts shall be collected prior to the patient seeing the medical provider

6 A charge sheet will be filled out electronically by the providersAali be attacAed to tAe pAysical ckaFt aAd f)laced iA tke desigAateEJ area

7 The clinical team will be alerted that the patient is ready to be seen

8 An effort will be made with each subsequent visit to correct any discrepancies (contact numbers addresses email etc)

9 When the diagnosis and treatment ofthe patient is completed tke f)atieAt skall be preseAteEJ a COf) of the slIf)erbill bull hich the patieRt skall preseRt to the recef)tioRist before leaiRg the ~the+Re-_receptionist shall compute the total charges due for the day and shall collect the appropriate amount from the patient

10 Arrangements for payment should be made prior to the patient being seen by the medical provider Arrangements for payment other than complete payment at the time of visit will be addressed by the-_BlIsiRess MaAagerExecutive Director

11 After hours packets are available in the trauma area The processing ofthese records may be different from normal office hours but will be completed as thoroughly as possible depending on the urgency of the clinical situation If all information is not able to be obtained during the visit a phone number will be provided by the patient so the billing department may follow up to obtain necessary information to be able to bill the patients claim The receptionist will also follow up if any additional documentation is required Signature for consent to treat is required in all situations

Lake Fork Health Service District Category Administrative Page 1 ofl Policy Patient Check-In Policy Number ADMINc)6

Effective Date

110109

Last Revised Date

10115a918

Reference 42CFR4917(b)(2)-Policies and Lines of Authority

Last Reviewed Date 10115~(aoI801lo9l2019

Purpose 42CFR4917(b(2) requires that this organizations policies and its lines of authority and responsibilities are clearly set forth in writing

Statement of Policy The Lake Fork Health Service District interprets 42CFR4917 (b)(2) to include administrative policies that cover topics including patient registration Therefore this clinic shall maintain an efficient process for established patient check-in to include changes to demographic insurance consents and medical history information useful to provide care

Health care providers will make every effort to see patients at their appointed time with the understanding that emergent andor unscheduled urgent problems of other patients may result in delays or even rescheduling

Procedure 1 Greeting patients and visitors is the responsibility of the receptionist All visitors and patients

are to be greeted pleasantly and treated courteously

2 The patient is responsible to verbally advise the receptionist oftheir presence in the clinic upon their arrival

3 The receptionist shall note the patients arrival in the computer system andi confirm the electronic chart anE lHIl tlle labents phtsical chart

4 Same-Day appointments are reserved on our schedule

5 Work-In (Walk-In) patients will be accommodated as possible and shall be seen on a first come first served basis or triaged appropriately

6 At the time of check-in the receptionist should confirm their current contact information (address email phone number and insurance company status) and make any changes to the patients record

7 The receptionist may change information as necessary in the system to ensure correct billing

8 All patients will be empaneled to the MDMedical Director


Category Administrative Page 1 of 2 Policy Statements and Collections Policy Number ADMIN-07


Last Revised Date 119Sa91S


Last Reviewed Date 11a9a91701l09l2019

Purpose

42CFR4917(b)(2) requires that this organizations policies and its lines of authority and responsibilities are clearly set forth in writing

Statement of Policy

The Lake Fork Health Service District interprets 42CFR4917 (b)(2) to include written policies that consist of administrative policies that cover topics including payment for healthcare services provided The District shall maintain a streamlined process regarding patient statements and collections

Patient service statements will be sent by Athena EMR(electronic medical records system)OR OF aFOllRd ~5t of each mORth

Past due messages will be added to the patient billing for account balances older than 60 days Collection attempts will be made by District staff until the account is past 120 days in arrears at which time it may be referred to an outside collection agency

Future services for accounts past 120 days in arrears or having a bad debt write-off in the past will be cash only sliding scale or other arrangement approved by the Board Treasurer

Bad Debt write-offs will be approved according to the Delegation of Authorities

Procedure 1 Charge and Payment information is managed by the District Billing Staff as defined in the

organization~ chart Billing staff will monitor accuracy of insurance charge and payment information into the District billing software

2 AthenaThe 8illiRg Staff will arrange for sending current patient account statements~-ampA--ef aFOllRd the 1st of each mORth

3 Past Due messages are automatically added as account balances age past 60 days

4 Collection attempts are initially managed by the District Billing Staff once the account is past 6~ days in arrears If there is no success or response collection effort will be escalated under the direction of the 8llsiRess MaRageF Executive Director up to and including referral to a collection agency

5 Prior to sending any patient to formal collection the Medical Director ampor the 8usiAess MaAager Executive Director will reviewapprove that action or consider writing the account off to Bad-Debt Write-offs will be approved according to the Delegation of Authorities

6 If an account is past 120 days old or has been written off to bad debt in the past future services provided by the clinic will be approved by the Board Treasurer as

a Cash only (requiring payment before service) b Sliding Scale c Or an approved special arrangement


Category Administrative Page 10fl

Policy Financial Arrangements Policy Number ADMIN()8

Effective Date

110109

Last Revised Date 1195a91amp

Reference 42CFR4917b)2)middotPolicies and Lines ofAuthority

Last Reviewed Date U30-2Q1~02l05l2019

Purpose


Statement of Policy

The Lake Fork Health Service District interprets 42CFR4917 (b)(2) to include written policies that consist of administrative policies that cover topics including payment for healthcare services provided Therefore this clinic shall maintain streamlined process regarding patients payment for services

Patient obligated charges for services are expected at the time of the visit No patient will be denied emergency treatment because of his or her inability to pay ASliding Fee Scale is available for qualified patients

Procedure

1 Financial arrangements can be made with the billing staff with appropriate review by the Treasurer Medical Director or- Executive DirectorBusifless Maflager depending on the size and nature of the arrangement

2 Receipts can be-be printedwrittefl 011 the eharge sheet hand written or on the credit card receipt

3 If the patient states heshe cannot pay in full an attempt to collect what the patient can pay will be made at that time

4 UAiflslued patieflts are offered a 25 diseollfIt (011 the fisit POrtiOR of the bill) if paid the da of the Fisit CORsideratiofl of this diseouRt eafl be made (if laid before the first statemeflt is seAt)

S1lnsured patients are responsible for any portion of their bill not covered by their insurance deductible co-insurance etc This should be paid at the time of visit if it can be calculated

ampiMedicare patients are responsible for the annual deductible (starting in Jan) plus 20 of the allowable amount

+sectColorado Medicaid requires a $200 co-pay for patients over 18 years of age each visit (collected at time of check-in)

8-LWritten application for the Sliding Scale is required (includes provision of tax returns)

-------- -----

I Lake Fork Health Service District

category Administrative Page 1 of 1 j

Policy Credit Policy Policy Number ADMIN-09

bull Effective Date 110109

Last Revised Date

1195a91amp Reference 42CFR4917(b)(2)-Policies and Lines of Authority

Last Reviewed Date Ua9lao1~02l06l2019

Purpose

42CFR4917(b)(2) requires that this organizations policies and its lines of authority and responsibilities

are clearly set forth in writing

Statement of Policy

The Lake Fork Health Service District interprets 42CFR4917 (b)(2) to include written policies that consist of administrative policies that cover topics including payment for healthcare services provided

The District shall maintain streamlined process regarding credit policy

Payment in full is expected for each visit with the following exceptions

bull Certain Preferred Provider Organizations (PPO) and Health Maintenance Organizations (HMO)

bull Medicare

bull Medicaid

All co-pays are due at check-in

Payment is due at the time of visit in those cases where patient insurance is not accepted by the District

Procedure

1 Medicaid patients 18 years and older shall pay the Co-Pay ($200) at time of check-in and in-full for non-covered services at Check-out

2 We are participating providers in the Medicaid Program we accept assignment on all claims Each patient will be responsible for any co-payor allowable amounts Supplemental insurance will be filed for them

3 For PPO patients We will accept assignment on all claims for covered services After we receive the Explanation of Benefits form (EOB) from insurance the patient will be billed for any remaining allowable balance Co-payments are due at Check-In

4 For YRiflsyreEi ~atieRts reFRiREI theFR of the 2S~ EliseoYRt if the Bill is ~aiEi OR the aat of the isit

Lake Fork Health Service District Category Administrative Page 1 ofl Policy Cash Receipt and Recording Charges Policy Number ADMIN-I0 Effective Date

110109

Last Revised Date 119i391i


Last Reviewed Date 11a9Jl a91703L06L2019

Purpose


Statement of Policy

The Lake Fork Health Service District interprets 42CFR4917(b)(2 to include written policies that consist of administrative policies that cover topics including payment for healthcare services provided Therefore this clinic shall maintain streamlined process regarding the recording of charges and the receipt of cash on clinic premises

Cash receipts shall be recorded immediately according to procedures following Cash on hand will be handled in a secure manner during the day and locked in the records room at the end of each business day

A balanced accounting for cash and banking will be made each day

Procedure

1 The clinical staff will provide a list ofcemf)lete the chaFge sheet te iRchIEle the isit ceEle testiRg dORe here medication~ given here courier fee and any supplies given to patient f)receElYFes The receptionist will collect applicable fees and provide a receipt the cemf)leteEi chaFge st-leet to the billing department

2 A cash drawer shall be maintained to facilitate making change when patients pay at the front desk The cash drawer balance is the responsibility of the front desk employee and Executive DirectorBysiReSS MaRager

3 In-office payments must be posted in Athena OR the chaFge tickets by the receptionist

4 Batch reports are created by billing personneltt-le BusiRess MaRager A daily deposit will be made for that amount

5 Daily bank deposits should include all receipts (mail and across the front desk)

6 A written explanation of any discrepancies or out-of-balance situations must be made on the batch summary report

Lake Fork Health Service District Category Administrative Page lof2 Policy Appointment Scheduling Policy Number ADMIN-ll Effective Date


11952915 Reference 42CFR4917(b)(2)-Patient Scheduling

Last Reviewed Date 03[06[20191129291+

Purpose


Statement of Policy

The lake Fork Health Service District interprets 42CFR4917 (b)(2) to include written policies that consist of administrative poliCies that cover topics including patient registration lake City Area Medical Center shall maintain a streamlined process to make appointments

Appointment scheduling will be maintained in the electronic health records system

Procedure

1 All appointments (New and Established) are scheduled using the Districts electronic health records system scheduling module Slot time-frames are built into the scheduler The only eA1J9lo(ees Raving seheEllAler lieenses e onl( hae two) are eA1J9loees orking tRe kont Elesl(

2 The Receptionist shall make a notation in the scheduler of a no-show or cancellation of appointments

3 Double booking may be necessary at times (esp in our busy season summer) The receptionist will need to know how that is done in the scheduler and should clear it with the clinical team

4 The first appointment of the day will be at 1000 with earlier appointments being held for phlebotomy and urgent appointments onl( for cSlAeatioA ansallsincss offiee eOAsllltatioAs

5 The final morning appointment will be scheduled no later than 1200

6 The first afternoon appointment shall be scheduled at 1300

7 The final afternoon appointment shall not be scheduled any later than 1600 (unless prior approval is given by the medical provider)

8 Patients are to be advised that appointment times are approximate

9 This Clinic accepts Same-Day and Walk-In patients

Same-Day Patients who call first to be seen the same day

Walk-In Patients who do not call first rather just show up to be seen

Patients are asked to check-in with the receptionist when they arrive and every effort is made to see patients near their appointment times and added patients in the order of check-in

10 This clinic must also serve as an UrgentEmergent Care facility those patients may require such attention as to cause cancellation rescheduling of all other appointments for a period of time

11 Appointments are normally made by the receptionist they can be made by anyone able to follow proper procedure

12 If a patient must be added to a full schedule consult the clinical team to determine the best time and what to tell the patient

13 The receptionist should advise all work-in patients that they will be worked into the appointment schedule The receptionist should further advise the patient of the approximate time they will be seen by the Medical Provider

14 New patients are asked to arrive at the clinic thirty minutes before their appointment time in order to complete the necessary forms These visits typically take longer (the provider needs to familiarize themselves with more historical information)

15 Patients scheduling an appointment in person shall receive a clinic card with the time and date for the appointment if desired Patients are also able to receive appointment reminder texts or calls if desired


Category Administrative Page 1 of2

Policy Termination of Care Policy Number ADMIN-12


Last Revised Date

11052015

Reference 42CFR4917(b)(2)-Policies and Lines of Authority and American Medical Association

Last Reviewed Date 04i17i20191aJa9ampgn

Purpose 42CFR49L7(b)(2 requires that this organizations policies and its lines of authority and responsibilities are clearly set forth in writing

Also according to the American Medical Association (AMA) abandonment is defined as the termination of a professional relationship between physician and patient at an unreasonable time and without giving the patient the chance to find an equally qualified replacement

Physicians have an obligation to support continuity of care for their patients While physicians have the option of withdrawing from a case they cannot do so without giving notice to the patient the relatives or responsible friends sufficiently long in advance of withdrawal to permit another medical attendant to be secured

Proper documentation is essential A doctors dismissal of a patient can be appropriate if there are multiple well-documented and clearly understood attempts by the doctor to discuss the issue with the patient as well as attempts to rectify the situation

Statement of Policy The lake Fork Health Service District interprets 42CFR49L7(b)(2) to include written policies that consist of administrative policies that cover topics including patient registration The District shall maintain a streamlined process for the termination of patient care should such termination be warranted

The following steps shall be taken when terminating care for a patient

bull Give the patient written notice preferably by certified mail return receipt requested

bull Provide the patient with a brief explanation for terminating the relationship (eg non-compliance failure to keep appointments)

bull Agree to continue to provide treatment and access to services for a reasonable period of time (30 days unless agreed otherwise) to allow a patient to secure care from another physician The period may be extended at the discretion ofthe Medical or Dental Director for emergency services

bull Provide resources andor recommendations to help a patient locate another physician of like specialty

bull Offer to transfer records to a newly-designated physician upon signed patient authorization to do so

Written documentation recording the doctors dismissal of a patient and the steps taken above shall be kept in the patient file

A Provider cannot terminate care of a patient on the basis of his or her gender race religion or sexual preference

Law enforcement shall be called immediately for any event involving the brandishing of a gun knife or other weapon or at the discretion of the provider on duty for situations deemed by senior staff on site as presenting a danger to staff volunteers patients or other occupants

Procedure 1 If a patient becomes violent physically or verbally abusive or threatening to clinic staff or other

occupants they may be asked to leave the premises Failure to comply will result in law enforcement being called That behavior would warrant beginning the process of termination of care by providers at the clinic

2 Any staff person encountering an individual using abusive andor offensive language during a telephone conversation is not expected to continue the conversation If the individual calls again the staff person is instructed to direct that call to the Provider on duty

3 The Medical and Dental Directors will determine whether to recommend continuation or termination of care at Lake City Area Medical Center or Dental Clinic respectively

4 A recommendation for termination of care would be reviewed by a representative of the Lake Fork Health Service District Board before implementation of termination of care proceedings

5 Termination of Care Procedure

a A letter by Certified Mail (with delivery receipt) shall be sent to the patient b That letter shall contain several components

1 Notify the patient of the reasons for this action by the District i1 Agree to continue provision of care for 30 days the purpose is to allow time for

the patient to secure care from another source iii Offer to provide resources andor recommendations to help locate another

appropriate source of care iv Offer to transfer records to the new care source once the patient signs

authorization to send those records

6 Every aspect of this action shall be well documented in the patient record

lake Fork Health Service District Category Administrative Page lof2 Policy General Phones and Patient Triage by Phone Policy Number ADMIN-13 Effective Date

110109 last Revised Date

11052015 Reference 42CFR4917(b)(2)-Policies and lines of Authority

last Reviewed Date 04l16l2019U~33~30n

Purpose 42CFR4917(b)(2) requires that this organizations policies and its lines of authority and responsibilities are clearly set forth in writing

Statement of Policy The Lake Fork Health Service District interprets 42CFR4917(b)(2) to include written policies that consist of administrative policies that cover topics including patient registration lake City Area Medical Center shall maintain a streamlined phone process for making appointments

Procedure

1 It is the responsibility of the receptionist to answer all incoming telephone calls and direct the call to the appropriate party Assistance may be provided by other office staff

2 Personal phone calls should not interfere with nor delay the primary function of clinic

3 The greeting may be similar to lake City Area Medical Center this is (name of person) May I help you Always identify yourself by name when speaking to someone on the telephone

4 Avoid placing the caller on hold if possible If it becomes necessary to do this frequently bring the matter up at staff meetings and attempt to find a solution or provide additional training If hold is unavoidable and continues more than a short period break in every 30 seconds or so and say Thank you for waiting May I call you back

5 All calls received shall be returned as soon as possible Within 30 minutes is suggested

6 If fees are requested by telephone inform the caller of the price for a 99213 charge for an ESTABLISHED patient and 99202 charge for a NEW patient State that it can vary and does not include fees for tests procedures or medications ie there may be additional charges for lab tests and other possible procedures

7 The Medical Providers will accept calls during the clinic hours as necessary trying to avoid delay in patient care

8 Ask the medical provider hisher preference before saying heshe is available to accept a telephone call

9 Telephone triage involves someone determining appropriate dispensation (ie emergent or immediate vs planned visit) based on a telephone inquiry The receptionist performs some phone triage every day The task may require a clinical staff member Generally all patients should be seen as soon as possible and preferably the same day

10 The telephone is to be answered promptly and pleasantly The receptionist shall ask the following questions of all patients requesting an appointment

a) What is the Patients name b) Have you been a patient at this clinic before c) Which medical provider do you want to see d) What does your current problem involve e) How long has the problem persisted

11 Get call-back information name of caller name of patient telephone number If the call is about an Established patient have that chart information ready with the message

12 In the event there are no time slots available the triage staff person shall consult a clinical team member for their opinion about how to advise the patient

13 A member of the clinical team shall contact the patientcaller and advise them of the preferred method of dealing with their situation (ie EMS emergency room add-on etc)

14 The Receptionist shall assist to make sure the telephone inquiries from patients are returned in a timely manner

Lake Fork Health Service District i


Policy Taking Messages by Request Type Policy Number ADMIN-14

i Effective Date

110109

Last Revised Date

11052015

Reference 42CFR4917b)(2)-Policies and Lines of Authority

Last Reviewed Date U~~~laQa~06l05l2019

Purpose


Statement of Policy

Lake City Area Medical Center interprets 42CFR4917 (b)(2) to include written policies that consist of administrative policies that cover topics including patient registration Therefore this clinic shall maintain streamlined phone process whereby patients may make an appointment to see a healthcare proVider or seek the counsel of their healthcare provider

Procedure

1 Messages can be delivered through the electronic health records (EHR) messaging system That is the preferred method (consideration taken for whether the reCipient will retrieve the message in an appropriate time)

2 When taking calls always obtain the callers name and purpose ofthe call The following is a list of responses for different types of calls

3 MEDICAL -- Include call back number name of person calling and time call came in After the call has been returned the message and response can be recorded in the patients chart

4 NEW RXs -- When a patient calls requesting a prescription be called in

A If the patient is new or has not been seen within the last 6 months must make an appointment

8 Get symptoms If there is any question as to whether the patient should come in always ask a nurse or provider

C Get name of pharmacy and a return number for the patient

S REFILLS -- Unless it is for a routine maintenance Rx ifthe patient has not been in within 6 months they must make an appointment

A Get the name of their medication the dosage the name of their pharmacy and the patients return phone number

B Explain that refills are sent electronically unless prohibited It is advised to check by phone before going to the pharmacy Ifthere is a reason not to prescribe a refill then someone will call to explain

6 TEST RESULTS -- Get the patients name type of test date performed and the location If it has been more than 2 days and we still do not have the test results make a note for the nurses to inquire about a problem

7 CALLS FOR PROVIDER(S) -- When someone asks to speak to one of the providers determine the nature of the call if it is medical business or personal

Each provider may have preferences ask the provider for that day

lake Fork Health Service District


Policy Service Complaints Policy Number ADMIN-15

Effective Date October 31 2012

last Revised Date OiJ08JaOl8

Reference

last Reviewed Date O~(08aOl806l05l2019

Purpose

Provide guidance and procedure for response handling and documentation of Lake Fork Health Service

District customer and patient complaints

Statement of Policy

All written service complaints will be promptly and fully investigated by the Executive Director If a

verbal complaint of a serious nature is received and the Executive Director is not available the provider

on duty will address the complaint immediately and ask that the complaint also be made in writing

Service complaints may be submitted in written form including email letter or form provided in the

Appendix of this Policy Medical Center staff will assist the submitter with completion of the Complaint

Form in a private setting if requested

Complaint handling will include assurance to the submitter that there will be no negative repercussions

or reprisals directed to the patient or customer that investigations will be discreet and that patient

confidentiality will be protected

The Executive Director will insure all facts are gathered and interviews are performed with relevant

parties Care will be taken to avoid assessing or implying blame or fault during the investigation The

Executive Director will report findings to the Medical or Dental Director

The investigation report is not a public record as it may contain patient and personnel information

The Medical Dental Director or Board of Directors are the only people authorized to make any public

comment on any complaint investigation or result

Resolution action taken and response will be the responsibility of the Executive Director

All written complaints will receive a final written response from the Executive Director An initial

response either verbal or written will be made to the submitter within 5 business days of delivery of

the complaint If the final response will exceed 30 days an interim status report should be provided

Final response will be made within a reasonable period of time but not to exceed 60 days

Procedure

1 Complaint Receipt -Immediately upon receipt of a written complaint the original will be provided

to the Executive Director An initial response will be made within 5 business days Submitters are

encouraged but not required to use the Complaint Form provided in the Appendix and is also

available at the front desk and on the company website

2 Log and Assignment - The Executive Director will log the written complaint on the form provided in

the Appendix of this Policy The supervisor of any involved staff member will be notified of the

complaint and investigation

3 Investigation - The investigation will be prompt and fair Additional information may be requested

from the person as needed Care will be taken to avoid assessing blame or fault during the

investigation

4 Report - The Executive Director will report findings to the Medical or Dental Director A summary

will be written by the Executive Director and will be included in the file It will include but not be

limited to

a Date time and location of incident

b Description of the incident

c Patient or customer name and contact information

d Patient or customer representative submitting complaint where applicable

e Medical Center staff involved and in what manner

f Names of any other witnesses or people in attendance

g Submitters account ofthe incident

h Staff account of the incident

i Witness supervisor or other accounts

5 Assessment and Recommendations - The Executive Director will base recommendations and any

action on the facts of the investigation

6 Response -Once written a copy of response will be maintained in a secured file held by the

Executive Director and the log will be noted Verbal or meeting responses may be made in addition

where appropriate

7 Disagreements - Disagreements with the investigation findings actions or response may be

submitted in writing to the Medical Dental Director OR the Health District Board of Directors for the

record These will be reviewed for any additional action

8 Annual Review - The Medical or Dental Director will review the Complaint Log annually to assess

any patterns recurring themes concerns or needs to initiate additional staff education coaching

or training or other process or procedural remedial action

9 If a verbal com~laiRt of a seriows Ratwre is received aRd the ElEeetltie Director is Rat a ailaele the

proider 011 dllt( will address the complaiAt immediatel aAd ask 1ollat the complaiAt also ee made if

writiAg


I Category Administrative Page 10f1 Policy Open Records Access and Retrieval Policy Number ADMIN-16 Effective Date

June 17 2014 last Revised Date

l1gSaglsect Reference Colorado Open Records Act (CORA)

last Reviewed Date Uaalagl~

Purpose

Provide compliance with Colorado Open Records Act (CORA) and establish records retrieval fees

Statement of Policy

Public documents and records will be made available upon request to members of the public unless

protected by an exception Requests will be reviewed to insure that documents and records provided

do not contain information that is protected under HIPPA or other statutes or regulations

The charge for finding copying and providing a document that is considered to be standard a nd routine

will be twenty five cents per page Requests not considered standard or routine will be determined by

the President of the Board and an appropriate fee determined If a CORA request results in research

and retrieval being done in order to comply with the request the first hour oftime spent will be without

charge and thereafter the charge will be thirty dollars per hour

Requests must be made in writing Review and approval will be by the Medical or Dental Director EH-or

Executive DirectorPresiEileRt eftlle BearEil et Direeters Fulfillment of approved requests will be

scheduled and completed within a reasonable period as determined by the reviewers

Procedure

The following procedure will apply to public requests for Health District records or information

1 The request must be made in writing to the Lake Fork Health Service District

2 The request will be reviewed by the Medical-ef-Dental DirectorQ-aM the Executive Director

PFesiEileRt as noted above

3 The request will be approved or rejected by the reviewers noted above

a If approved appropriate office staff or volunteer(s) will be instructed as to which records

will be provided and when The requester will be notified in writing of the approval and

expected timing of fulfillment The requester will be reminded of the hourly and per page

billing rate and expectation of payment on receipt ofthe documents

b If not approved the requestor will be given a written response within 7 days including

reasons why the request is not approved

4 Approved requests will be fulfilled within a reasonable period as noted above

S A bill for hours spent and number of pages will be provided to the-Executive DirectorB~siRess

MaRager who will forward to the requester Payment for services will be expected prior to release

of the records to the requester

6 A record of all requests and related actions will be kept in office files


~ Administrative Page lof3

Policy Tobacco-free policy Policy Number ADMIN-17

Effective Date I Last Revised Date Reference May 1 2015 11012016 LFHSD Tobacco Policy

i Last Reviewed Date 11211191107102019

Purpose

The purpose of this policy is to establish a 100 tobacco-free workplace and to address nicotine

addiction It is the policy of LFHSD to prohibit tobacco and nicotine use or the use of any electronic

smoking device or other non-FDA approved products on LfHSD property

Tobacco use remains the leading cause of preventable disease and death in the United States The use

of these products has many effects including health problems for the individual using the product

environmental effects through second-hand smoke exposure and fire hazards as well as a financial

impact including increased medical expenses and productivity loss LFHSD is taking a leadership role on

the major public health issue of tobacco use by prohibiting tobacco and nicotine use in the workplace

and anywhere within its property boundaries

Statement of Policy

LFHSD is committed to the health and safety of staff patients visitors and business associates To

promote LFHSDs commitment to public health and safety and to reduce the health and safety risks to

those served and employed at this workplace all LFHSD property are tobacco-free as of 11012016

This policy applies to the smoking of cigarettes Cigars or pipes or the use of chewing or spit tobacco

electronic nicotine delivery systems non-FDA approved devices or other tobacco products The use of

any of these products or non-fDA approved devices will NOT be permitted on any LfHSD properties on

or after 11012016

This policy is applicable to all staff on LFHSD property whether they are employees of LFHSD or other

agencies and to all patients visitors students volunteers vendors lessees and contractors

LFHSD does not require staff patients or visitors to stop using tobacco however it is required that

people do not use tobacco on LFHSDs physical site or use tobacco during work times Employees will

not be allowed to smoke or use any tobacco products during their paid work time and are encouraged

not to use tobacco products during their unpaid work time

LFHSD wishes to maintain good relationships with its neighbors so trespassing on lOitering on or

littering on neighboring properties are not permitted This includes public right-of-ways including

neighboring sidewalks lawns and alleyways

Accountability

It is the shared responsibility of all LFHSD staff members to enforce the tobacco-free environment policy

by encouraging their colleagues patients visitors and others to comply with the policy Staff members

should communicate this policy to clients and visitors with courtesy and respect If staff members

encounter difficulty with enforcing this policy they should contact their supervisor

General Policy Provisions

1 No tobacco products or related paraphernalia will be used anywhere on LFHSD property

2 Signs declaring the LFHSD property tobacco-free will be posted at entrances

3 LFHSD employees will be advised of the provisions of this policy during New Employee

Orientation

4 Job announcements for all pOSitions on LFHSD property will display a notice that LFHSD has

a tobacco-free environment policy

Definitions

Electronic Smoking Device means any device that when activated emits a vapors aerosol fume or smoke can be used to deliver nicotine or any other substance to the person inhaling from the device including but not limited to e-cigarettes e-cigars e-pipes e-hookahs vape pens inhalant delivery systems of any other similar product by any other name or descriptor

IfTobacco Non-FDA Approved Nicotine Delivery Products or Other Devices means cigarettes cigars pipes pipe or rolling tobacco tobacco substitutes (eg clove cigarettes) chewing or spit tobacco or any type of electronic smoking device

lake Fork Health Service District Category Administrative Page 10f2 Policy Travel Compensation Policy Number ADMIN-iS Effective Date

5192015 last Revised Date 3ltQi~ag3i

Reference IRSGOV

last Reviewed Date U~3~~3Ql~07l10l2019

POLICY

Employees will be paid for travel time in compliance with the Fair labor Standards Act (FLSA) and applicable state regulations

It is the policy of the Lake Fork Health Service District (lFHSD) to reimburse staff for reasonable and necessary expenses for approved travel on behalf of LFHSD LFHSD strongly encourages use of travel discounts when making travel arrangements

ROCEDURE

A Approval- the BlIsiAess MaAager Executive Director must be aware of all travel requests

B When Paid - Travel time is considered hours worked and must be paid time when traveling

a from hisher regular place of work b for Company business (such as attendance at meetings or seminars)

C To and From Home - Travel time from an employees home to the work site and from the work site to home is not paid time

D Current Rate of Pay - Travel time must be paid at the employees current rate of pay and included when computing overtime pay

E MileageParking Expenses - Employees using their own vehicle for travel in conjunction with this policy should be reimbursed for mileage and for applicable tolls and parking expenses

F Calculated From Place of Work - Travel to attend meetings or seminars should begin at the employees regular place of work rather than their home

G Credit Cards- Employees are expected to use their own credit cards for travel unless otherwise arranged The employee shall submit travel expenses

H Actual Expenses- The LFHSD will reimburse expenditures on an actual basis according to the following parameters

a Meals Up to $4500 combined per day for Breakfast Lunch amp Dinner Covered meals extend following departure from Lake City and prior to arrival back in Lake City

b Lodging LFHSD will reimburse lodging for reasonable single occupancy or standard business room rates at reasonably priced mid-market hotels and motels When the hotel or motel is the conference site reimbursement will be limited to the conference rate

c Transportation Rental car economy $4500 per day d Airfare Most economical available

Lake Fork Health Service District Category Administrative Page lof4 Policy Space Rental Policy Number ADMIN-19 Effective Date


ampamp(9amp1391amp Reference LFHSD Mission

Last Reviewed Date UI~~1~91~07l10l2019

Purpose

This policy provides the District position and guidelines on renting space in the Moseley Health Care

Complex

The Mission of the LFHSD liThe mission of the Lake Fork Health Service District is to enhance the quality

of life in our community by promoting wellness and providing quality health services with care and

compassion while exercising fiscal responsibility

Statement of Policy

Space within the Moseley Health Care Complex (MHCC) is available for rental and use to individuals

organizations and businesses that provide service consistent with the mission of the District provide

service for the overall good of the community or present a commercial opportunity for the benefit of

the District

Use for political meetings or events or on the subject of controversial or questionable issues as

determined by the Board will not be allowed Examples include those that are divisive in nature or

promote activities that are contra to the health of individuals orthe community

Space rental may be for recurring or non-recurring use Examples of recurring use include but are not

limited to physiotherapy orthopedists monthly meetings massage therapy fitness classes or yoga

classes Examples of non-recurring use include but are not limited to meetings conferences education

events or ad hoc professional visits

Priority is given to unforeseen or unpredictable needs where the Complex is especially suited for

emergency or other unplanned use Examples include but are not limited to incident management by

emergency services organizations for major catastrophic events major wildfire and epidemics

Documentation of expectations and agreements in advance is strongly encouraged Space Rental

Agreements are generally required for recurring use Memoranda of Understanding (MOU) are

generally used for non-recurring use

Fees charged are to cover expenses of building operation wear and tear and not make the event a

burden on the taxpayers ofthe County It is the responsibility ofthe space user the Complex staff and

Health District Directors to protect the assets and interest of the District taxpayers with regard to the

Complex

Fees will be waiiea fer AeA pFefit aAa geterAFAeAtal ageACY Ilse Fees charged for private organizations

and businesses will be negotiated with the- Executive DirectorBeara af Direeters BlIsiAess

DelelapFAeAt CeFAFAittee Chair DeRatieAs are eRcellrageEi here apprepFiate especially fer these

whese fees have beeR alvea

Failure of the provider to follow the agreement will result in immediate termination of the activity and

will remain so until reviewed by the lFHSD Board of Directors The 81lsiRess MaRager Executive

Director Medical Director or Board President will have the power to immediately terminate any activity

due to agreement non-performance The space renter may appeal to the Board of Directors to be

reviewed at the next regular meeting

Procedure All users of Complex space are required to understand and adhere to the following guidelines of

reasonable use and behavior

bull No excessive noise or disturbances Use shall not interfere with operations of EMS the Medical

Center the Dental Clinic or other space users

bull Sponsors will be responsible for supervision of event cost and clean up and make clear that

lFHSD is not sponsoring the event

bull No banners signs or decorations outside rented space except for minimal signage on the door or near the door to identify the space user and any entry restrictions (eg do not enter while class or treatment in progress)

bull Service providers will not solicit business from core business patients on the MHCC premises Any advertising or identification of the space renter business is limited to business cards and minimal temporary signage sufficient to identify space being used at that time Signage will be done in a professional manner as determined by the Medical Director and Board

bull A clean up fee will be charged if rented space is not left in original condition This would include

removal of all trash Any trash more than the minimum items will be removed by the user All

trash that is odorous or may become odorous will be removed immediately and properly

disposed of Hazardous waste will be removed and properly disposed of

bull Conference or meeting events held during normal Medical or Dental clinic hours will require

that renters not use the parking lot in front of the Complex (reserved for patients) or in marked

employee parking in back Some parking in the back the adjacent lot on the north side and

street parking is available

bull Rooms must be scheduled for use with the Medical Center receptionist Medical and Dental

clinic EMS and lFHSD Board have first priority and right of preemption

bull Space is reserved on a first come first served basis

bull Where needed an access key to area must be signed out and returned immediately after event

bull Room dividers are not to be moved without supervision or training in use

bull Audiovisual and other electronic equipment is not to be used without proper training and must

be properly shut down following use

bull Rooms must be returned to pre-use conditions Chairs and tables should be re-positioned as

before the event

bull The kitchen area is available for use but must be cleaned if used after event

bull After use all lights should be turned off the key returned and any damage or equipment not

working properly reported to the receptionist If any cleaning is required the event user will be

billed

bull Illegal use of controlled substances is not allowed on Health District property Alcohol use is

governed by separate policy ADMIN-17 Exceptions to prohibition of legal alcohol use may be

granted under ADMIN-17 and must be in writing in the user agreement The event sponsor is

responsible for appropriate control during the event

bull No smoking or tobacco use is allowed in the Complex building or within a reasonable distance

from entrances as defined in ADMIN-17

Space rental agreements will include but not be limited to provisions on the following

bull liability and indemnity - Renters providing health services or sponsoring events with planned physical activities may be required to provide liability insurance for the protection of the District liability releases signed by participants may be substituted for insurance at the discretion ofthe Health District representative whenever it is unreasonable to expect the space user to obtain insurance Requirements for liability and indemnity coverage for space users that do not have planned physical activities may be waived at the discretion ofthe Health District representative Examples are business meetings training conferences and education classes

bull Fees and rentals - Each space rental agreement will include payment of a reasonable rental to

the M HCC for use of the facility negotiated by the Business Development Committee The

space rental fee for each agreement may differ according to the circumstances

bull Space scheduling and reservations The space renter will schedule their space needs under the

rental agreement in a timely manner as determined by the ExecutiveMeaieal_Director with

MHCC staff assigned to manage space rental schedules

bull Equipment - As a general rule the space renter is expected to provide their own equipment

bull Patient collections - The service provider will handle all collections of their patient fees unless

expressly negotiated by the 811siReSS MaRager Executive Director -or Medical Director and

approved by the Board

bull Appointments and inquiry handling - The space renter is responsible for their appointment

scheduling and answers to inquiries where applicable

bull licensing of providers - Medical and well ness service providers will provide proof of license in

those cases where the service provided requires licensing It is the responsibility of the renter to

provide any change in license status immediately to the 811siReSS MaAagcr Executive Director-or

Medical Director

bull Subleasing and renter employees - Subleasing of the rented space will not be allowed Space

renters and their employees will be expected to conduct themselves in an orderly and

professional manner under the direction of the service provider

bull Patient privacy - Medical and wellness service providers will insure patient privacy by

appropriate handling of their space signage and other appropriate measures HIPPA and other

patient protection regulations and laws will be strictly followed for the providers patients and

any incidental scenarios involving MHCC patients

Lake Fork Health Service District category Administrative Page 10fl Policy Business Development Policy Number ADMIN-20 Effective Date

May 20 2011 Revisedew Date

lltOSlaDlS Reference LFHSD Mission

Last Reviewed Date 08l07l2019Ill~~IiO~

Purpose

Following is our Statement of Policy for business development matters for the Lake Fork Health Service District (LFHSD) functioning in the Moseley Health Care Complex (MHCC) and doing business as the Lake City Area Medical Center (LCAMC) or Lake City Dental (LCD)

The mission of the Lake Fork Health Service District is to enhance the quality of life in our community by

promoting wellness and providing quality health services with care and compassion while exercising

fiscal responsibility

Statement of Policy

The LFHSD Board of Directors will engage in business development activities to rent space and provide

services in MHCC to health care providers for the benefit of the LFHSD its taxpayers and the

community of Lake City Businesses operating in the MHCC will

bull Provide service in a manner consistent with the Mission of the LFHSD

bull Provide service in accordance with the laws ordinances and regulations of the Town of Lake City Hinsdale County the State of Colorado and the United States of America federal government

bull Provide service that enhances the health of the individual served and the well-being of the community in general

bull Follow the additional guidelines and requirements specifically noted in the Space Rental Policy

Non-core LFHSD services that will be considered as appropriate for provision on MHCC premises include

additional medical and dental activities not already provided by MHCC

Business Development Policy - Definitions

bull Core Medical and Dental Business - The MHCC core business is providing high quality medical and dental care to those in need including but not limited to citizens of Lake City and surrounding communities seasonal and vacation residents and visitors This includes medical and dental services provided by LCAMC amp LCD staff

bull Non-Core Health Care Service - Non-core services include additional health care service provided by qualified and appropriately licensed providers NOT employed by MHCC but operating and providing service on MHCC premises under a written space rental agreement and approved by the Board of Directors of the LFHSD These fall in 3 categories for the purposes of this policy

o Tier 1 - Medical and Dental Professionals - This includes licensed medical and dental professionals performing traditional health care services eg physicians dentists cardiologists orthopedists etc

o Tier 2 - Traditional Support Services - This includes standard support services eg physical therapy nutritionist dental hygienist mental health etc

o Tier 3 - Ancillary I Alternative Disciplines - This includes additional traditional and nonshytraditional disciplines that promote I support health and well-being but not generally considered conventional medical services eg massage therapy hypnotism acupuncture etc

bull Community Meeting and Conference Facilities - The MHCC has meeting and conference facilities available to businesses and organizations for multiple uses Reservation and use of these facilities will be governed by a separate policy and operating procedure

bull EMS Facilities - Dedicated space for EMS and use of common areas are agreed between Hinsdale County and MHCC in a separate agreement

Procedure

Tier 1 and 2 services as defined above will be considered by the Business Development Committee

(Executive Director BllsiRess MaRager and 2 Board Members) and an appropriate space rental

agreement will be developed and executed by the executive directore Ireloses to the BoaFs fer

appretal

Tier 3 (Ancillary Disciplines) The Business Development Committee will have an initial discussion on the

merits ofthe proposed service to insure it is consistent with the Mission ofthe LFHSD supports the

improvement of patient well-being and is generally valued by the community Once a proposed Tier 3

ancillary service passes initial screening above an appropriate space rental service agreement can be

developed by the Executive DirectorBllsiReSS MaRager aRs proposes to the Beare for appreial

Relationship Non-core medical providers are simply renting space and are not under service contract to LFHSD or MHCC They are NOT employees of the LFHSD or MHCC and will not do anything to imply or present themselves as employees contractors or affiliates They will not take direction with regard to providing their service from any employee of the MHCC except for activities related to compliance with the space rental agreement They will not engage MHCC employees to assist in providing the ancillary service

Lake Fork Health Service District category Administrative Page 1 of 1 Policy Apartment Use Policy Number ADMIN-21

Effective Date Feb 6 2013

Last Revised Date uit9i~aolS

Reference

Last Reviewed Date 08l07l2019ampampita8i(agamp~

Purpose

The purpose of this policy is to provide guidelines and guidance for the administration and use of the

two apartments located upstairs in the Zeller Well ness and Conference Center

Statement of Policy

The apartments are provided as an incentive or cost avoidance option for temporary housing of out-ofshy

town visitors or workers according to the guidelines below Any use ofthe apartments that is not

connected to medical center operation training or other direct benefit is discouraged Use which is

deemed to be in direct competition of lake City commercial lodging is discouraged

The apartments are provided for use at no or minimal charge to the following types of users

bull Visiting contract volunteer or employed medical staff bull Visiting contract or volunteer trainer or educational personnel engaged in presentation

development or delivery of medical or health related subjects

Procedure

Apartment use requests will be evaluated by the Executive DirectorBl-Jsiness Manager for compliance

with policy

Arrangements for compliant uses will be coordinated by the front desk staff Apartment users will be

issued a door lock code and advised of District policies regarding smoking controlled substances and

alcohol (ADMIN-16) Users will be advised they are liable for any damages

Reservations and scheduling of apartments will be logged on the whiteboard in the hallway adjacent

to the Supply Room Scheduling conflicts will be resolved by the_-Executive DirectorBl-Jsincss Managcr

lake Fork Health Service District category Administrative Page lof1 Policy Company Email Use Policy Number ADMIN-22 Effective Date Jul162018

last Revised Date 07162018

Reference

last Reviewed Date 08l07l2019Q~J(i~(W8

Purpose

The purpose of this policy is to provide guidelines and guidance for the use of business email

Statement of Policy

Employees and board members (USERS) should only use company provided email systems for business purposes Email users are not expected to respond to company email outside of workbusiness hours Password protected accounts should be used to send emails Company email may be setup on personal devices as needed Company email should not be used for personal reasons All email may be monitored as needed

If an email user will be absent for an extended period of time an out of office message should be set If an email user leaves the company that persons email will forward to an appropriate replacement for a period of not less than 3 months

The email users may be held liable for sending or forwarding emails with any harassing defamatory

offensive racist or obscene remarks or unlawfully forward confidential email Users should avoid

replying all unless necessary

Email users should understand the importance of proper and professional email content including

replies The email user is representing the company and should portray a professional image on behalf

of the company

In order to keep all patient information secure emails are never to be used for patient discussion

Procedure

Email users will be provided with a personal login for the companys email system All company email

correspondence in regards to the business and its affiliates will be processed through the company

provided email All users will be courteous when using the company email and will also avoid any

harassing offensive or racist language Company email accounts should be password protected Email

accounts will be monitored as needed

bull I bull

( SIGNATURE RE~tHEDl FOR REIVEI1tACEBT Benefit by Trust

8RANCH

75W4

Lake City Area Medical Center Renewal and Optional Monthly Rates Effectille January 01 2020

art IIIiIIM __DIIIIIIIllltA U 117 LIiICta bullbull1-

r~ r ~ ~ r bull ~ v ~ I Iimiddot

MecIiaII (PPO Z) current $865 $1902 $1816 $1816 $2166 1$600 deductible) _I $895 $1969 $1110 $1110 $uez 35OMo

Medlclll (PPO J) current $713 $1568 $1497 $1497 $1785

1$1000 deductible I reMWIIl $738 $1623 $1549 $1549 $1847 350

Medlclll (PlIO 4) current $656 $1442 $1377 $1377 $1639

$15OO deductibleI rentIWIIIl $679 $1491 $1425 $1425 $1696 35m(

Medical (PlIO 5) current $602 $1328 $1268 $1268 $1508

($2500 deductibleI _I $amp23 $1374 $1312 $1312 $1561 350

Medical (PPO 6) current $555 $1222 $1166 $1166 $1389

($3000 deductibleI ~al $574 $1265 $1z07 $1lO7 $14J1 35OK

Medical (PlIO 7) current $510 $1125 $1072 $lOn $1277

1$4000 deductible AlllllWal $528 $1164 $1110 $1110 $13Zl 350

Medical (PfIOI) current $485 $1069 $1018 $1018 $1213

($5000 deductible) -1 $502 $1106 $1054 $1OSI $1255 35OK

Medical (EPa 3) current $656 $1442 $1377 $1377 $1639

($1000 hospital copay) nIfteWIIl $679 $lM2 $1425 $1425 $1_ 35OK

MfldlcaI (PO 4) current $595 $1308 $1248 $1248 $1484

($1500 hospital capay) nlRllWal $616 $1354 $1291 $1292 $153G 35OK

MedIcal (epa 5) current $566 $1242 $1187 $1187 $1410

($2500 hospital capay) _I $S86 $1115 $1Zl9 $1229 $1459 350

current $558 $1Z29 $1173 $1173 $1395C~-($2800 deductible) ren_1 $578 $1272 $1214 $1214 $1444 3L]

Medlcaf (H035OO) current $513 $1131 $1079 $1079 $1283

1$3500 deductlblfl lIMWal $531 $1171 $1117 $1117 $1328 350

MedIcal (H05OOO) current $463 $1018 $972 $972 $1157

($5000 deductible I IIIMWIII $479 $11JS4 $1006 $1OOfi $1197 350

MedicalIHRP) current $275

_I $275

~n1-th tViJ Jot130 I 3(1- 1laamp2 1~2

Dental PI3n A (wortho) current $43 $96 S116 $116 S156

IS OOl lgtalllliax) renewal $43 $96 $116 $116 $156 000

Dental Plan 8 (wortho) current $36 $75 $103 S103 $139 --shyIS SOO lhallVax renewal $36 $75 $103 $103 $139 ~ ~-

Dental Plan C(wo ortho) current $36 $75 $68 $68 $115

IS SOP i lliax renewal $36 $75 $68 $68 $115 000

lision Plan A current $6 513 $11 $11 $17

renewal $6 $13 $11 $11 $17 000

VIsion Plan 8 (l5P) current $10 514 $13 $13 $24 ---shyrenew1 $10 $14 $13 $13 $Z4L2l I -J

VIsion Plan C(lSP) current $13 S18 $17 S17 $31

11 Ili ) renewal $13 $18 $17 $17 $31 000

Employee life RateD1414 iI $UlO [0 eruKe)

Dependent life RateO96

IS~ JOO )I lt amp $1000Chlld)

-Yoer sIgna below acknowledges receIpt of the (EST Renewal and Optional Rates but does rot bind your renewal - To crnplte yOU groups renewal all documents marked Signature Required For Renewal must be Signed and returned to Willis TOWNS Watson preferablv by 05-OIlltLll1J 019

-In ]ccordanee with your participation agreement wnttennotice oltermlnatior must be received by Ivem~r~ll or rwn out cilims w I rot be paId by CFBT

Receed by _____________________ Date _______

Title ________________________ 75W4

CEBT Benefit by Trust

CEBT BENEFIT amp ADMINISTRATIVE CHANGES (Effective January 12020)

tEBT Plan Changes

Medical

Colonoscopies Remove age limit for routinepreventive services on all plans (PPO EPO HD)

HDnoo will become HD2800 Deductible will increase from $2700(individual)$S400(family) to $2800(individual)$5600(familv) No change to the maximum out-of-pocket

United Healthcare Network Will change from Options PPO to Choice Plus This will result in an JD card reissue lor all members under the UHC network option

Dental

Addition of Right Start 4 Kids program (Plans A B amp Cl Applicable to dependent children to the age of 13 (through age 12) No deductible on all services All services paid at ]00 up to the plan year maximum (subject to annual maximums and limitations does not apply to orthodontia)

Addition of Prevention First program (plans A B amp C) Preventive services will be covered at 100 and will nOt be applied to the annual maximum ThiS will make the annual maximum go farther for other non-preventive services

Dental Plan A changes Increase annual maximum from $1750 to $2000 Add adult orthodontia (current $2000 mal( is applicable)

Jolllntary Lifr

bull Employee Max Benefit will increase from $300k to $500k

bull Employee Guarantee Issue (GI) amount will increase from SlOOk to $150k bull Spousal max coverage will increase from a flat $10k to increments of $lDk up to $250k with GI of $30k 1not to exceed

50 of the employee max)

bull Child coverage will increase from $5k to $20k

bull PartICipants who elect coverage during initial enrollment will have the option to increase their benefits evefy year a1 open enrollment up to $20k with no medical underwriting

bull True Open Enrollment will be allowed with GI at groups annual enrollment (Januafy 2020 or July 2020) for all groups currently offering Voluntary life

bull New and improved rates effective upon annual enrollment (1120 for January renewal groups and 7120 for July

renewal groups)

LAKE FORK HEALTH SERVICE DISTRICT BOARD OF DIRECTORS-SPECIAL MEETING

Todays Date is Thursday August 22 2019 1 The regular monthly meeting of the Lake Fork Health Service District was called to order by Janel Warren at 900 AM

The meeting was held in the Moseley Health Care Complex

II Roll Call In attendance were board members Janel Warren Mike Schell Lynn McNitt and Jerry Johnson Jessica Whiddon Bernie Krystyniak Ashley Mines Nancy Zeller and Bruce Uchida were also present Malinda McDonald is the recording secretary

Board of Directors

President Janel Warren Vice-President Jami Scroggins Secretary Mike Schell Treasurer Lynn McNitt Board Member Jerry Johnson

III Workshop A Executive Director Report- Medical patient counts through June 2019 were 1364 vs

1595 through June 2018 A difference of 231 patients Dental patient counts through June 2019 were 353 versus 393 through June 2018 A difference of 40 patients

~ Business Development- None ~ Community Relations- Ad for Sunday closing October-April

~ Personnel- None

2 President Reports None

3 Medical Director Reports None

4 Dental Director- None

IV MEETING







(President) Date

(Secretary) Date



Category Administrative Page 10f2 Policy Protection of Record Information on District Premises





























Procedure























8 Complete request














following











I

I






















































Effective Date

110109

Last Revised Date

10115a918





















Purpose


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Effective Date

110109




Purpose


Statement of Policy



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Last Revised Date



Purpose



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bull Medicare

bull Medicaid



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110109




Purpose


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11052015



































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i Effective Date

110109

Last Revised Date

11052015



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investigation



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with policy








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bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)

IV MEETING







(President) Date

(Secretary) Date
































Procedure























8 Complete request














following











I

I






















































Effective Date

110109

Last Revised Date

10115a918





















Purpose


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Effective Date

110109




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-------- -----





Last Revised Date



Purpose



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110109




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Last Revised Date

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i Effective Date

110109

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Accountability









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before the event




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Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


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bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)































Procedure























8 Complete request














following











I

I






















































Effective Date

110109

Last Revised Date

10115a918





















Purpose


Statement of Policy

















Effective Date

110109




Purpose


Statement of Policy



Procedure









-------- -----





Last Revised Date



Purpose



Statement of Policy





bull Medicare

bull Medicaid



Procedure






110109




Purpose


Statement of Policy




Procedure











Purpose


Statement of Policy



Procedure























Last Revised Date

11052015



































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i Effective Date

110109

Last Revised Date

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Procedure










investigation



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with policy








Reference


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Statement of Policy








of the company


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bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)















8 Complete request














following











I

I






















































Effective Date

110109

Last Revised Date

10115a918





















Purpose


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Effective Date

110109




Purpose


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-------- -----





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110109




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i Effective Date

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with policy








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bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)






following











I

I






















































Effective Date

110109

Last Revised Date

10115a918





















Purpose


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Effective Date

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bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)








I

I






















































Effective Date

110109

Last Revised Date

10115a918





















Purpose


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bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)
























Lake Fork Health Service District Category Administrative f 2 Policy New Patient Registration Policy Number ADMIN-OS Effective Date Last Revised Date Reference





















Effective Date

110109

Last Revised Date

10115a918





















Purpose


Statement of Policy

















Effective Date

110109




Purpose


Statement of Policy



Procedure









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Last Revised Date



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with policy








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bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)





































Effective Date

110109

Last Revised Date

10115a918





















Purpose


Statement of Policy

















Effective Date

110109




Purpose


Statement of Policy



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Last Revised Date



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with policy








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bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)







Purpose


Statement of Policy

















Effective Date

110109




Purpose


Statement of Policy



Procedure









-------- -----





Last Revised Date



Purpose



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bull Medicaid



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110109




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i Effective Date

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Purpose


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Statement of Policy




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with policy








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Purpose


Statement of Policy








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bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)







Effective Date

110109




Purpose


Statement of Policy



Procedure









-------- -----





Last Revised Date



Purpose



Statement of Policy





bull Medicare

bull Medicaid



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110109




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Statement of Policy




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Last Revised Date

11052015



































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i Effective Date

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Last Revised Date

11052015



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investigation



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Orientation



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Purpose


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Reference


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with policy








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Purpose


Statement of Policy








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bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)

-------- -----





Last Revised Date



Purpose



Statement of Policy





bull Medicare

bull Medicaid



Procedure






110109




Purpose


Statement of Policy




Procedure











Purpose


Statement of Policy



Procedure























Last Revised Date

11052015



































Procedure



















i Effective Date

110109

Last Revised Date

11052015



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Statement of Policy


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where appropriate









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POLICY



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Statement of Policy




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with policy








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Statement of Policy








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bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)





Last Revised Date



Purpose



Statement of Policy





bull Medicare

bull Medicaid



Procedure






110109




Purpose


Statement of Policy




Procedure











Purpose


Statement of Policy



Procedure























Last Revised Date

11052015



































Procedure



















i Effective Date

110109

Last Revised Date

11052015



Purpose


Statement of Policy


Procedure



















Reference


Purpose



Statement of Policy





















Procedure










investigation



limited to














where appropriate









writiAg






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Orientation



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POLICY



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Purpose


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Statement of Policy




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Statement of Policy


















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Reference


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with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)


110109




Purpose


Statement of Policy




Procedure











Purpose


Statement of Policy



Procedure























Last Revised Date

11052015



































Procedure



















i Effective Date

110109

Last Revised Date

11052015



Purpose


Statement of Policy


Procedure



















Reference


Purpose



Statement of Policy





















Procedure










investigation



limited to














where appropriate









writiAg






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Orientation



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Reference IRSGOV


POLICY



ROCEDURE

















Purpose


Complex




Statement of Policy




the District

















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before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)





Purpose


Statement of Policy



Procedure























Last Revised Date

11052015



































Procedure



















i Effective Date

110109

Last Revised Date

11052015



Purpose


Statement of Policy


Procedure



















Reference


Purpose



Statement of Policy





















Procedure










investigation



limited to














where appropriate









writiAg






Purpose


Statement of Policy












Procedure






















Purpose










Statement of Policy







or after 11012016










Accountability









Orientation



Definitions





Reference IRSGOV


POLICY



ROCEDURE

















Purpose


Complex




Statement of Policy




the District

















Complex


































before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)













Last Revised Date

11052015



































Procedure



















i Effective Date

110109

Last Revised Date

11052015



Purpose


Statement of Policy


Procedure



















Reference


Purpose



Statement of Policy





















Procedure










investigation



limited to














where appropriate









writiAg






Purpose


Statement of Policy












Procedure






















Purpose










Statement of Policy







or after 11012016










Accountability









Orientation



Definitions





Reference IRSGOV


POLICY



ROCEDURE

















Purpose


Complex




Statement of Policy




the District

















Complex


































before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)





















Procedure



















i Effective Date

110109

Last Revised Date

11052015



Purpose


Statement of Policy


Procedure



















Reference


Purpose



Statement of Policy





















Procedure










investigation



limited to














where appropriate









writiAg






Purpose


Statement of Policy












Procedure






















Purpose










Statement of Policy







or after 11012016










Accountability









Orientation



Definitions





Reference IRSGOV


POLICY



ROCEDURE

















Purpose


Complex




Statement of Policy




the District

















Complex


































before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)











i Effective Date

110109

Last Revised Date

11052015



Purpose


Statement of Policy


Procedure



















Reference


Purpose



Statement of Policy





















Procedure










investigation



limited to














where appropriate









writiAg






Purpose


Statement of Policy












Procedure






















Purpose










Statement of Policy







or after 11012016










Accountability









Orientation



Definitions





Reference IRSGOV


POLICY



ROCEDURE

















Purpose


Complex




Statement of Policy




the District

















Complex


































before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)










Reference


Purpose



Statement of Policy





















Procedure










investigation



limited to














where appropriate









writiAg






Purpose


Statement of Policy












Procedure






















Purpose










Statement of Policy







or after 11012016










Accountability









Orientation



Definitions





Reference IRSGOV


POLICY



ROCEDURE

















Purpose


Complex




Statement of Policy




the District

















Complex


































before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)

Procedure










investigation



limited to














where appropriate









writiAg






Purpose


Statement of Policy












Procedure






















Purpose










Statement of Policy







or after 11012016










Accountability









Orientation



Definitions





Reference IRSGOV


POLICY



ROCEDURE

















Purpose


Complex




Statement of Policy




the District

















Complex


































before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)






Purpose


Statement of Policy












Procedure






















Purpose










Statement of Policy







or after 11012016










Accountability









Orientation



Definitions





Reference IRSGOV


POLICY



ROCEDURE

















Purpose


Complex




Statement of Policy




the District

















Complex


































before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)







Purpose










Statement of Policy







or after 11012016










Accountability









Orientation



Definitions





Reference IRSGOV


POLICY



ROCEDURE

















Purpose


Complex




Statement of Policy




the District

















Complex


































before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)




Accountability









Orientation



Definitions





Reference IRSGOV


POLICY



ROCEDURE

















Purpose


Complex




Statement of Policy




the District

















Complex


































before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)



Reference IRSGOV


POLICY



ROCEDURE

















Purpose


Complex




Statement of Policy




the District

















Complex


































before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)








Purpose


Complex




Statement of Policy




the District

















Complex


































before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)


Complex


































before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)




before the event




billed
























Medical Director












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)












Purpose





Statement of Policy


















Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)






Procedure




appretal










Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)




Reference


Purpose



Statement of Policy








Procedure


with policy








Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)



Reference


Purpose


Statement of Policy








of the company


Procedure






bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)

bull I bull


8RANCH

75W4





























_I $275








renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)







renewal $6 $13 $11 $11 $17 000



11 Ili ) renewal $13 $18 $17 $17 $31 000






Receed by _____________________ Date _______

Title ________________________ 75W4



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)



tEBT Plan Changes

Medical




Dental




Jolllntary Lifr








renewal groups)

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