Molina Medicaid Solutions - DHHR

exv10w24Regulations, section 1300.71.38 and the demonstration of good cause for the delay, accept, and adjudicate the claim according to CaliforniaHealth & Safety Code section 1371 or 1371.35, which ever is applicable, and the California Code of Regulations.HSA — Hospital Services AgreementMolina ECMS ref# 729 Provider or authorizedMHC v122706 / MHI v091707 representative’s initials:Pacific Hospital of Long BeachPage 31 of 40ATTACHMENT FDHCS ProvisionsThe following provisions apply exclusively to Covered Services provided and activities engaged in pursuant to Medicaid Program:1. All Medicaid covered services are set forth in Attachment C and the Provider Manual as set forth in this Agreement. (Rule 53250(c)(1))2. This Agreement shall be governed by and construed in accordance with all laws, regulations and contractual obligations incumbent upon theHealth Plan. (Rule 53250(c)(2))3. This Agreement shall become effective upon approval by the Department of Health Care Services (“DHCS”) in writing, or by operation of lawwhere the DHCS has acknowledged receipt of this Agreement and has failed to approve or disapprove the Agreement within 60 days of receipt.(Rule 53250(c)(3))4. Amendments to this Agreement shall be submitted to the DHCS, for prior approval, at least thirty (30) days before the effective date of anyproposed changes governing compensation, services or term. Proposed changes which are neither approved nor disapproved by the DHCS, shallbecome effective by operation of law thirty (30) days after the DHCS has acknowledged receipt, or upon the date specified in the Amendment,whichever is later. (Rule 53250(c)(3))5. Provider agrees to submit all reports required and requested by Health Plan, in a form acceptable to Health Plan. (Rule 53250(c)(5))6. Provider shall make all of its books and records, pertaining to the goods and services furnished under the terms of this Agreement, available forinspection, examination or copying:a. By the DHCS, the United States Department of Health and Human Services, the DMHC, and the Department of Justice;b. At all reasonable times, at Provider’s place of business or at such other mutually agreeable location in California;c. In a form maintained in accordance with the general standards applicable to such book or record keeping;d. For a term of at least five years from the close of the fiscal year in which the date of service occurred, in which the record or data wascreated or applied, and for which the financial record was created;HSA — Hospital Services AgreementMolina ECMS ref# 729 Provider or authorizedMHC v122706 / MHI v091707 representative’s initials:Pacific Hospital of Long BeachPage 32 of 40e. Including all encounter data for a period of at least five years. (Rule 53250(e)(1))7. Provider agrees to notify the DHCS in the event that this Agreement is amended or terminated. Notice to the DHCS shall be considered givenwhen properly addressed and deposited in the United States Postal Service as First Class Registered Mail, postage attached.http://sec.gov/Archives/edgar/data/1179929/000095012310025132/a55407exv10w24.htm[1/6/2012 11:13:06 AM]