Questions
for Deletion of Service Site
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Site
Name
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Site
Address
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Date
Site Proposed for Deletion was Added to Scope:
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Site
Added/Used as Part of ARRA or ACA Grant?
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1.
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BACKGROUND
AND JUSTIFICATION FOR DELETION
Provide
brief background/justification for why your health
center is proposing to remove this service site from
your scope of project (e.g. major decrease in patient
population, financial recovery plan, etc.). In
providing background, specify whether the site will
actually be closed or whether the site will remain
open but the health center will no longer include it
in its scope of project.
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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2.
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PROPOSED
DATE OF SITE DELETION
When
do you plan to close/leave and/or stop providing
services at the site?
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(mm/dd/yyyy):
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3.
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MAINTENANCE
OF LEVEL AND QUALITY OF HEALTH SERVICES
Clearly
describe in a brief narrative format, the health
center's plan for assuring that the deletion of this
service site will
in no way result in the diminution of the health
center's total level or quality of health services
currently provided
to the patient/target population of the current site.
In discussing this plan, provide the following
information for each of the locations where patients
will receive services following the deletion of the
site:
Site/Provider
Name
Site/Provider
Address
Provider
Type (e.g. existing site of your health center, site
of another health center, other safety net provider -
specify, any other provider type - specify, etc.).
Availability
of a sliding fee discount programs and/or other
programs at such locations that assure no health
center patient will be denied health care services
due to an individual's inability to pay for such
services.
If
the service site to be deleted was added to scope
through a HRSA-funded application (e.g. New Access
Point or Capital Grant), the health center MUST state
this and must specifically address if and how the
patient and visit projections included in the approved
application for the site, will be maintained.
In
addition, respond to ALL of the questions below (3a. –
3f.), which must align with and support this
narrative.
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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3a.
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Describe
if and how deletion of the site will
impact access to any health center services
(Required or Additional) in the current approved scope
of project (as reflected on the health center’s
Form 5A).
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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3b.
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What
is the number of patients that will be affected by the
deletion of the service site? What proportion of the
overall patient population (i.e. across all sites in
scope) does this represent?
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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3c.
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Average
travel time for patients to service location(s)
discussed in Question 3.
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Currently:
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hrs
mins
(Format:99)
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Following
Deletion:
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hrs
mins
(Format:99)
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3d.
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Average
miles traveled by patients to service location(s)
discussed in Question 3.
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Currently:
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miles
(Format:
9 or 9.99)
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Following
Deletion:
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miles
(Format:
9 or 9.99)
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3e.
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Will
enhanced and/or increased transportation services be
available to assure access to all health center
services for patients served by the site proposed for
deletion?
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Yes
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No
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Explain
both Yes and No responses.
Maximum paragraph(s)
allowed approximately: 3 (3000 character(s)
remaining)
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3f.
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Describe
how the health center will address any other barriers
to care that the deletion of the service site may
present.
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
Optional:
Upload any attachments relevant to the site deletion
here that support the health center’s assurance
that the total
level or quality of health services currently provided
will be maintained (e.g.
maps, transportation plans etc.).
Maintenance
of Quality & Level of Health Services Supporting Documentation
(Maximum 6 attachments)
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Select
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Purpose
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Document
Name
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Size
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Uploaded
By
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Description
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No
attached document exists.
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4.
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CONTINUITY
OF CARE AND COLLABORATION
In
4a and 4b, describe your health center's plans for
ensuring continuity of care for current patients
affected by the site deletion as well as plans for
maintaining existing and/or establishing new
collaborative relationships within the service area.
For
the purposes of this question:
Collaborative
relationships are those that assist in contributing to
one or both of the following goals relative to the
patients served by the site that will be deleted:
(1)
maximizing access to required and additional services
within the scope of the health center project to the
target population that is served at the site to be
deleted; and/or
(2)
promoting continuity of care to health care services
for health center patients served at the site to be
deleted beyond the scope of the project.
Collaboration
Resources
Collaboration
PAL:
http://bphc.hrsa.gov/policiesregulations/policies/pal201102.html
UDS
Mapper: http://www.udsmapper.org
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4a.
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Describe
outreach and communication plans for informing current
health center patients and the community at large, of
the site deletion including making them aware of any
new or enhanced transportation or enabling services
available to access services at other sites or
locations.
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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4b.
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Describe
plans for informing providers (e.g. section 330
grantees, Look-Alikes, rural health clinics, critical
access hospitals, health departments, etc.) in or
adjacent to the service area of the site that is
proposed for deletion and for maintaining current or
establishing new collaborative relationships with such
organizations. If no other providers exist within or
adjacent to the service area state this.
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
Optional:
Upload any attachments relevant to the site deletion
here that support the health center’s continuity
of care plan and/or collaborative relationships (e.g.
sample patient notification documents, local media
announcements about site deletion, new MOUs, etc.).
Continuity
of Care Plan & Collaboration Supporting Documentation (Maximum 6
attachments)
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Select
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Purpose
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Document
Name
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Size
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Uploaded
By
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Description
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No
attached document exists.
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Click
"Save" button to save all information within
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5.
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SITE
OWNERSHIP AND OPERATION
If
the site to be deleted is operated by a contractor or
subrecipient, respond to the appropriate set of
questions (5a. OR 5b.) below.
Health
centers are reminded of their responsibilities to
obtain any required prior approval from HRSA for
aspects of the program conducted by subrecipients or
contractors before a subrecipient or contractor can
undertake an activity or make a budget change
requiring that approval, e.g., delete a contractor or
subrecipient operated site from scope, seek approval
to extend the period of performance of a subaward to a
subrecipient if it would extend beyond the end of the
grant's project period.
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IF
SITE TO BE DELETED IS OPERATED BY A CONTRACTOR
5a.
If
the site is owned and/or operated by a third party on
behalf of the health center through a written
contractual agreement between the health center and
the third party (i.e. the health center is purchasing
a specific set of goods and services from the third
party-such as the operation of a site) respond to all
of the following questions:
Have
(or will, based on site deletion date) all
applicable records and documents of activities
performed by the contractor on behalf of the health
center in the operation of the site, been transferred
to the health center PRIOR to the site's
removal/closure? This
should include at minimum:
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Yes
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No
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Has
the health center followed their own board-approved
procurement policies and procedures for terminating
contractual agreements with third parties, including
assuring access to all applicable financial, program
and property management systems and records, as well
as receiving (or ensuring provisions to receive) any
final and complete financial and programmatic reports?
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Yes
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No
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Optional:
Attach any supporting documentation here.
Site
Ownership and Operation Supporting Documentation A (Maximum 6
attachments)
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Select
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Purpose
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Document
Name
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Size
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Uploaded
By
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Description
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No
attached document exists.
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IF
SITE TO BE DELETED IS OPERATED BY SUBRECIPIENT
5b.
If
the site is owned and/or operated by subrecipient on
behalf of the health center through a written
subrecipient agreement between the health center and
the subrecipient organization to perform a substantive
portion of the grant-supported program or project,
respond
to all of the following questions.
A
subrecipient is an organization that "(ii)(I) is
receiving funding from such a grant under a contract
with the recipient of such a grant, and (II) meets the
requirements to receive a grant under section 330 of
such Act . . ." (1861(aa)(4) and 1905(l)(2)(B) of
the Social Security Act).
Subrecipients
must be compliant with all of the requirements of
section 330 to be eligible to receive FQHC
reimbursement from both Medicare and Medicaid.
The
subrecipient arrangement must be documented through a
formal written agreement (Section 330(a)(1) of the
PHS Act)
The
health center (grantee of record) named on the NoA is
the entity legally accountable to HRSA for performance
of the project or program, the appropriate expenditure
of funds by all parties including subrecipients, and
other requirements placed on the health center
(grantee of record), regardless of the involvement of
others in conducting the project or program.
Has
(or will, based on site deletion date) the
subrecipient responded to all applicable final
programmatic, administrative, financial, and reporting
requirements of the grant, including those necessary
to ensure compliance with all applicable Federal
regulations and policies to the Grantee of Record?
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Yes
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No
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Has
(or will, based on site deletion date) the health
center Grantee of Record reviewed all final documents
related to providing funding to the subrecipient,
including dollar ceiling, method and schedule of
payment, type of supporting documentation required,
and procedures for review and approval of expenditures
of grant funds?
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Yes
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No
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Optional:
Attach any supporting documentation here.
Site
Ownership and Operation Supporting Documentation B (Maximum 6
attachments)
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Select
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Purpose
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Document
Name
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Size
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Uploaded
By
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Description
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No
attached document exists.
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Click
"Save" button to save all information within
this page.
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6.
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FINANCIAL
IMPACT ANALYSIS
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Template
Name
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Template
Description
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Action
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Financial
Impact Analysis
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Template
for Financial Impact Analysis
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Instructions
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Instructions
for Financial Impact Analysis
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Attach
Financial Impact Analysis Document here.
Financial
Impact Analysis (Maximum 6 attachments)
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Select
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Purpose
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Document
Name
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Size
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Uploaded
By
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Description
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No
attached document exists.
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Explain
how adequate
revenue will continue to be generated to cover
existing expenses across the overall scope of project
incurred by the health center. If the overall scope
and total budget of the health center will be reduced
as a result of the site deletion, specify this. The
Financial Impact Analysis must at a
minimum show a break-even scenario or the potential
for generating additional revenue.
Maximum paragraph(s) allowed
approximately: 3 (3000 character(s) remaining)
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7.
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HEALTH
CENTER STATUS
Discuss
any major changes in the health center’s
staffing, financial position, governance, and/or other
operational areas, as well as any unresolved areas of
non-compliance with Program Requirements (e.g. active
Progressive Action conditions) in the past 12 months
that might impact the health center’s ability to
implement the proposed change in scope.
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Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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8.
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SERVICES
Will
this site deletion result in the deletion of any
services currently included within the approved scope
of project as documented on your health center’s
Form
5A?
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Yes,
but a separate CIS request(s) to remove these
service(s) from scope will be submitted.
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No
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"Save" button to save all information within
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Additional
Considerations for Deleting a Site from Scope
While
the following areas are not specific
factors or criteria that will impact the CIS approval
process, these are key elements that health centers
should have considered or actively plan to address
prior to deleting a service site from the scope of
project.
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A.
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Medical
Malpractice Coverage:
For
grantees deemed under the Federal Tort Claims Act
(FTCA), be aware that FTCA coverage is limited to the
performance of medical, surgical, dental, or related
functions within the scope of the approved Federal
section 330 grant project, which includes sites,
services, and other activities or locations, as
defined in the covered entity's grant application and
any subsequently approved change in scope requests.
Confirm
that your health center is aware that if the request
to delete this site is approved, FTCA coverage will no
longer extend to any activities, services, providers,
etc. at the deleted site as of the date of the
approval to remove the site from scope.
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Yes,
health center is aware that removing this site from
scope will result in the loss of FTCA coverage for
the deleted site.
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N/A,
health center is not deemed or FTCA coverage does
not apply.
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For
more information, the FTCA Health Center Policy Manual
is available
at:http://www.bphc.hrsa.gov/policiesregulations/policies/pin201101.html
For specific questions, contact the BPHC HelpLine at:
1-877-974-BPHC (2742) or Email: [email protected].
Available Monday to Friday (excluding Federal
holidays), from 8:30 AM - 5:30 PM (ET), with extra
hours available during high volume periods.
Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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B.
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Section
340B Drug Pricing Program Participation:
Health
centers that participate in the 340B Drug Pricing
Program are reminded that sites added or deleted from
the scope of project through the BPHC change in scope
process do not automatically update within the 340B
Program's Database. Health centers should contact the
HRSA Office of Pharmacy Affairs to determine whether
any updates to the 340B Database are necessary by
contacting Apexus Answers at 888-340-2787, or
[email protected]
.
Will
your health center complete all necessary 340B Program
updates with the HRSA Office of Pharmacy Affairs?
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Yes
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N/A,
health center does not participate in the 340B
program
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Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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"Save" button to save all information within
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C.
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Reimbursement
as a Federally Qualified Health Center (FQHC) under
Medicare, Medicaid and CHIP:
Services
provided at sites that are included under a health
center's HRSA-approved "scope of projects"
are generally eligible for reimbursement by Medicaid,
Medicare, and CHIP under the FQHC payment systems.
When a health center receives HRSA approval to delete
a site from its scope of project, it must cease
billing for services provided at this site under these
FQHC payment systems as of the date that the site was
removed from scope. The health center is also
responsible for informing Medicare and Medicaid that
the site has been removed from scope and is no longer
eligible for reimbursement under the FQHC payment
systems.
Will
your health center stop billing Medicare, Medicaid and
CHIP under the FQHC payment system for services
provided at this site effective on the date that the
site was approved to be removed from your scope of
project?
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Yes
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N/A
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Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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Will
your health center contact Medicare and Medicaid to
inform them that the site is no longer within your
scope of project and therefore no longer eligible for
reimbursement under the FQHC reimbursement systems?
For
Medicare, health centers should contact the enrollment
office at their Medicare Administrative Contractor;
for Medicaid, health centers should contact the
enrollment office at their State Medicaid Agency.
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Yes
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N/A
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Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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D.
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National
Health Service Corps Program Participation:
Health
centers that participate in the National Health
Service Corps (NHSC) are reminded that all NHSC
participants must continue to work ONLY at an approved
site within the health center's scope of project. In
addition, the NHSC must be kept aware of all changes
in site addresses and NHSC participant site
assignments.
NHSC
sites and participants may contact the NHSC through
the Customer Service Portal
(https://programportal.hrsa.gov/extranet/landing.seam)
or through the Customer Care Center by calling
1-800-221-9393.
In
deleting this site from your scope of project, has
your health center assessed the impact on any NHSC
participants that might currently be working at the
site and advised them that they will need to seek a
site reassignment with the NHSC prior to beginning
work at another site in scope?
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Yes
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N/A,
health center does not have any NHSC participants
at this site.
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Briefly
explain your response:
Maximum
paragraph(s) allowed approximately: 3 (3000
character(s) remaining)
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