Wisconsin In-Network Transportation Provider Checklist

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or created or received by BUSINESS ASSOCIATE on behalf of LGTC, is destroyed or returned toLGTC, or, if it is not feasible to return or destroy, protections are extended to such information.5. Termination for Cause. Upon LGTC’s knowledge of a material breach by BUSINESSASSOCIATE of the terms of this Agreement, LGTC shall either:a. Provide an opportunity for BUSINESS ASSOCIATE to cure the breach or to end theviolation within a time specified by LGTC. Should the BUSINESS ASSOCIATE not cure the breach norend the violation within the time specified by LGTC, LGTC may terminate the Prior Agreementimmediately without penalty; orb. Immediately terminate the Prior Agreement if BUSINESS ASSOCIATE has breached amaterial term of this Agreement and cure is not possible; orc. If neither termination nor cure is feasible, LGTC shall report the violation to the Secretary.6. Indemnification. BUSINESS ASSOCIATE shall indemnify and hold LGTC harmless from andagainst all claims, liabilities, judgments, fines, assessments, penalties, awards, or other expenses of anykind whatsoever, including, without limitation attorney’s fees, witness fees, and costs of investigation,litigation or dispute resolution, relating to or arising out of any breach or alleged breach of this Agreementby BUSINESS ASSOCIATE.7. Miscellaneous:a. Binding Nature. This Agreement shall be binding on the Parties hereto and theirsuccessors and assigns.b. Article Headings. The article headings used are for reference and convenience only, andshall not enter into the interpretation of this Agreement.c. State Law. To the extent any applicable state law confidentiality requirements are notpre-empted by HIPAA, BUSINESS ASSOCIATE agrees to comply with such state law requirements.d. Third Party Participants. BUSINESS ASSOCIATE agrees that any of LGTC’s Clientsto whom BUSINESS ASSOCIATE provides services and with whom LGTC has entered into a BusinessAssociate agreement are third party Participants of this Agreement.Notwithstanding the foregoing, no other individual or entity shall be considered a third partybeneficiary of this Agreement.e. Amendment. CLIENT and BUSINESS ASSOCIATE agree that amendment of thisAgreement may be required to ensure that BUSINESS ASSOCIATE and CLIENT comply with changesin state and federal laws and regulations relating to the privacy, security, and confidentiality of PHI.IN WITNESS WHEREOF, LGTC, and BUSINESS ASSOCIATE have caused this Agreement to besigned and delivered by their duly authorized representatives, as of the date set forth above.LOGISTICARE SOLUTIONS, LLCPROVIDER(Print or Type Provider Name)Date:Signature:Printed Name:Title:Date:Signature:Printed Name:Title:Wisconsin NET ProgramVersion: March 25 2011Page 36
EXHIBIT DDEFICIT REDUCTION ACT OF 2005FRAUD, WASTE AND ABUSE POLICYFederal law requires that entities such as LogistiCare and its subsidiaries that receive at least$5 million in annual payments under a State Medicaid program establish written policies for itsemployees, contractors and agents that furnish detailed information regarding the federal andstate False Claims Acts, the administrative remedies available under the acts, other protectionunder the acts, and the Company’s procedures for detecting fraud, waste and abuse.LogistiCare’s policy is to provide detailed information to all employees, contractors and agentsabout federal and state False Claims Acts and the Company’s policies and procedures to detectand prevent fraud, waste and abuse. The information in this policy forms part of its employeemanual, its transportation provider manual, and is distributed to all contractors and agents asrequired by the Deficit Reduction Act of 2005.Federal False Claims ActThe federal False Claims Act, among other things, applies to the submission of claims byhealthcare providers for payment by Medicare, Medicaid and other federal and state healthcareprograms. The False Claims Act is the federal government’s primary civil remedy for improperor fraudulent claims. It applies to all federal programs, from military procurement contracts towelfare benefits to healthcare benefits.The False Claims Act prohibits, among other things:• knowingly presenting or causing to be presented to the federal government a false orfraudulent claim for payment or approval;• knowingly making or using, or causing to be made or used, a false record or statement inorder to have a false or fraudulent claim paid or approved by the government;• conspiring to defraud the government by getting a false or fraudulent claim allowed orpaid; and• knowingly making or using, or causing to be made or used, a false record or statement toconceal, avoid, or decrease an obligation to pay or transmit money or property to thegovernment.• “Knowingly” means that a person, with respect to information: 1) has actual knowledgeof the information; 2) acts in deliberate ignorance of the truth or falsity of theinformation; or 3) acts in reckless disregard of the truth or falsity of the information.Enforcement• The United States Attorney General may bring civil actions for violations of the FalseClaims Act. As with most other civil actions, the government must establish its case byWisconsin NET ProgramVersion: March 25 2011Page 37
Page 1 and 2: Please return all documents to:1275
Page 3 and 4: TRANSPORTATION AGREEMENT(the “Agr
Page 5 and 6: Provider may be withdrawn by LGTC,
Page 7 and 8: ii)iii)iv)scheduled B-Leg pick up t
Page 9 and 10: utilized by Provider.ii) The number
Page 11 and 12: • ADA regulations;• Client Cont
Page 13 and 14: vi)type of vehicle in which it is i
Page 15 and 16: and satisfactorily cleared a nation
Page 17 and 18: ix)a Participant, or in the presenc
Page 19 and 20: iv)Provider warrants that it has no
Page 21 and 22: a) name, date of birth and social s
Page 23 and 24: from establishing or maintaining se
Page 25 and 26: the dispute shall be referred for b
Page 27 and 28: EXHIBIT ALIQUIDATED DAMAGESThe Part
Page 29 and 30: Requirement:Provider must perform t
Page 32 and 33: To determine the payment amount LGT
Page 34 and 35: Exhibit B - Execution PageLOGISTICA
Page 36 and 37: scope of the employment or other pr
Page 40 and 41: presenting a preponderance of the e
Page 42 and 43: EXHIBIT EMedicare Advantage Program
Page 44 and 45: information and data necessary for:
Page 46 and 47: e reviewed and approved by Health P
Page 48 and 49: Non-Emergency Medical Transportatio
Page 50 and 51: LOGISTICARE INSURANCE CREDENTIALING
Page 52 and 53: Please describe your hours of opera
Page 54 and 55: Network Development503 Oak Place, S
Page 56 and 57: AFTER HOURS CONTACTINFORMATION SHEE
Page 58 and 59: Form W-9 (Rev. 1-2003) Page 2Exampl
Page 60 and 61: Form W-9 (Rev. 1-2003) Page 4Part I
Page 62 and 63: Dear LogistiCare Transportation Pro
Page 64 and 65: Electronic Data Interchange (EDI) A
Page 66 and 67: Date: __________________________Log
Page 68 and 69: Software User AgreementWHEREAS, Log
Page 70 and 71: III.OWNERSHIPThe Software is protec
Page 72 and 73: X. THIRD PARTY WEBSITESThe Software
Page 74 and 75: (B) The Content may not be copied,
Page 76 and 77: this Agreement, or the infringement
Page 78 and 79: LogistiCare Driver ListLegal name D

Wisconsin In-Network Transportation Provider Checklist

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