Checklist for Adding a Service to Scope

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Checklist for Adding a Service to Scope
Background
Your change in scope (CIS) request will not become part of your health center’s HRSA-approved Health Center Program scope of project until all the following steps have been completed: 
    1. HRSA sends your health center the Notice of Award (NoA) or Notice of Look-Alike Designation (NLD) approving the CIS request; 
    2. Next, your health center submits a scope verification task that confirms your health center has implemented the change. HRSA will allow up to 120 days for your health center to submit the scope verification task; and 
    3. Finally, HRSA sends your health center an NoA or NLD documenting that the change is included in your health center’s scope of project. 
For more information, refer to the Scope of Project Resources. 
    1. Has your health center recently submitted or is it in the process of submitting any other CIS requests related to this service or related to any attachments within this CIS request? For example, contracts or arrangements within this CIS request are referenced within other CIS requests or your health center previously submitted a CIS request to add this service that HRSA disapproved.
    • Yes 
    • No 
 
        1.1 If YES: Provide the CIS tracking numbers and describe the connection to this CIS request.
For example, the same contract, same cooperative arrangement, why you are submitting another CIS request for this service that HRSA previously disapproved.
 [textbox] 

    2. Is this CIS request a scope correction in preparation for or resulting from one or more site visits?
    • Yes 
    • No 

        2.1 If YES: Identify the related site visits.
[textbox] 

        2.2 If YES: Explain. [textbox] 


Description and Rationale
    3. Why are you requesting to add this proposed service to your health center’s scope of project? Select all reasons that apply:

    • An existing provider is no longer offering this service to the patient population in the area. Explain: [textbox]
    • Your health center has an opportunity to expand access. Explain: [textbox]
    • Other – Explain: [textbox]
    4. Did another entity or party contact your health center and request that this service be provided to the proposed patient population? 
        ◦ Yes
        ◦ No

        4.1 If YES: Explain how the proposed service will be provided on behalf of your health center.
[textbox]

    5. Provide a description of: 
        5.1 The service, such as the specific procedures to be provided (refer to the Form 5A Service Descriptors).
[textbox]
        5.2 All staff who will be involved in providing the service (providers, contractors, or support staff).
[textbox]

    6. Attach a copy of the provider privileging lists for the proposed service.

[attachment – multiple possible, with at least one required]

    7. Will this service be offered at all of your health center’s service sites?
    • Yes
    • No

        7.1 If NO: Describe your health center’s plan for ensuring all patients (this includes current and new patients across all in-scope sites) can access the service. Explain how any transportation needs or travel barriers will be addressed.  

If this service can only be accessed through a contract (Column II-only) or cooperative arrangement (Column III-only), you must describe how your health center will address patient transportation needs. 
[textbox]
    8. How will your health center ensure patients accessing this service will have access to all of your health center’s other in-scope services?
[textbox]
    9. Provide annual data only for the proposed new service: 
       
        9.1 Projected new patients who will receive the service.
[textbox]
        9.2 Projected current patients who will receive the service.
[textbox]
        9.3 Total projected patients (sum of projected new patients and projected current patients)
[textbox]
        9.4 Of the total projected patients, anticipated percentage of patients with incomes at or below 200 percent of the Federal Poverty Level Guidelines.
[textbox]
        9.5 Briefly explain how these projections were derived.
		[textbox]

    10. Provide data about the need for this service in your health center’s service area and for the proposed patient population, using one or more of the following sources:
    • UDS data (for example, UDS trend data); 
    • Data on the characteristics of the patient population to be served; 
    • Data on associated risk factors (for example, occupational, environmental, behavioral, social, housing status);
    • Other community-based data (such as survey, focus group, wait times).
[textbox]
Additional Service

    11. If you had to select “Other” in order to propose the service on Form 5A: Services Provided: How will the proposed additional service support the provision of one or more required primary health services provided by your health center either directly or via contract?
[textbox]

Note: Not all additional care is appropriate for inclusion within the Health Center Program scope of project. 
Service Provided Via Contract or Subaward
    12. Who will be billing and collecting for the proposed Column II service? [multi-select]
    • My health center
    • The contractor or subrecipient

    13. Attach a copy of your health center’s contract with the contractor or subaward agreement with the subrecipient for the proposed service and, if needed, other documentation agreed to by both your health center and the contractor or subrecipient. 

The attachments must contain the complete contract or subaward agreement executed by all parties (for example, a signed paper copy, electronically-signed documents, or emails documenting acceptance). The attachments must include any additional documentation, such as appendices or addenda.

Within the attachments, clearly mark or highlight the language that addresses each criterion. 

Provide the citation (for example, page numbers) for where each criterion is addressed in the attached documentation. You may provide additional narrative if necessary.

[attachments – multiple, with at least one required]

        13.1 The specific services to be performed by the contractor or subrecipient.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        13.2 The process for exchanging patient information between the health center and contractor or subrecipient to ensure patient access to services. 
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        13.3 How the health center will access patient medical records or documentation of services provided , consistent with applicable laws—specifically, the right of the health center to access the contractor’s or subrecipient’s patient health records related to the services provided on behalf of the health center. For example, laboratory, radiology, or other results.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        13.4 How contractor or subrecipient credentialing and privileging will be accomplished.
Note: The contract or subaward agreement language can be general and reference a more comprehensive process or policy. Credentialing and privileging for a contractor’s or subrecipient’s providers may happen in many ways. For example, an individual contracted provider or a locum will participate in the health center’s credentialing and privileging program. In another example, the contractor has its own credentialing and privileging program, and the health center has reviewed that program for compliance.

Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        13.5 How your health center will pay or provide funding to the contractor or subrecipient for services the contractor or subrecipient delivers on behalf of your health center.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        13.6 For subrecipients or if the contractor bills and collects for services: The ability of the health center to review the contractor’s or subrecipient’s billing and collections process and sliding fee discount schedule to ensure compliance with Health Center Program requirements. 
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        13.7 The applicability of federal and state laws including those related to patient privacy, HHS grant regulations, and civil rights, and any other requirements of your health center’s federal award.
Note: A contract or subaward agreement provision that requires the parties to comply with all laws generally (sometimes called a “catch-all” provision) may satisfy this criterion.

Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]


Note: The contract or subaward agreement must address any additional applicable requirements, including those identified in Chapter 12: Contracts and Subawards of the Health Center Program Compliance Manual.

Service Provided Via Cooperative Arrangement
    14. If this service can only be accessed through this cooperative arrangement, describe how your health center will assist patients in making an appointment for the service. Otherwise, respond “not applicable.” [textbox]

    15. Describe how your health center will provide care coordination as well as follow-up care, based on the care and instructions provided by the other party. [textbox]

    16. Attach a copy of your health center’s cooperative arrangement with the other party for the proposed service and, if needed, other documentation agreed to by both your health center and the other party. 

The attachments must contain the complete cooperative arrangement executed by all parties (for example, a signed paper copy, electronically-signed documents, or emails documenting acceptance). The attachments must include any additional documentation, such as appendices or addenda.

Within the attachments, clearly mark or highlight the language that addresses each criterion. 

Provide the citation (for example, page numbers) for where each criterion is addressed in the attached documentation. You may provide additional narrative if necessary.

[attachments – multiple, with at least one required]

        16.1 The specific activity(ies) or services to be performed by the other party.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        16.2 The process for exchanging patient information between the health center and the other party to ensure patient access to services.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        16.3 How patient medical records or documentation of services provided will be maintained and shared with your health center. Specifically, the process for the other party to provide information to your health center related to the services provided by the other party, such as follow-up instructions or laboratory, radiology, or other results.
Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        16.4 How the other party will apply a discount to its schedule of charges for services it provides to health center patients. 
Note: The other party’s schedule of charges may differ from a health center’s schedule of charges.

Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

        16.5 Any provisions required by federal and state laws, including those related to patient privacy and civil rights.
Note: A cooperative arrangement provision that requires the parties to comply with all laws generally (sometimes called a “catch-all” provision) may satisfy this criterion. 

Citation within the attached (for example, page numbers): [textbox]
Brief Narrative: [textbox]

Reminder: If any information in this CIS request is incomplete, HRSA may disapprove this CIS request.


Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) are patient-directed organizations that deliver affordable, accessible, quality, and cost-effective primary health care services to patients and adjust fees based on income and family size. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/2029. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 13N82, Rockville, Maryland, 20857 or [email protected].  Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.