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HomeMy WebLinkAbout5.652 Original Contract 5. u;5~ PROFESSIONAL SERVICES AGREEMENT This AGREEMENT made this 3rd day of September, 2003 by and between the City of Port Angeles ("City") and Systems Design Northwest, Inc., a Washington corporation. ARTICLE I - DESCRIPTION OF SERVICES Systems Design Northwest, Inc. agrees to provide billing services to the City for its ambulance transportation services, which services shall be in accordance with recognized standards for ambulance transport billing services and shall be in accordance with applicable government rules and regulations. Responsibilities of the City: 1. Apply for "Provider Status" with Medicare, DSHS, Labor & Industries, and any private insurance company which will be billed. 2. Complete the Medical Incident Report ("MIR"), including patient name, address, and pertinent billing information. 3. Forward MIRs, hospital face sheets, and copies of payments made to the City to Systems Design Northwest, Inc. on a weekly basis. 4. Provide additional information as may be required by insurance companies or agencies in order to complete the processing of billing ambulance charges. Responsibilities of Systems Design Northwest, Inc.: 1. Entry of Account/Patient records. 2. Entry of all charges, payments, and adjustments. 3. Production and mailing ofHCFA 1500 forms for all insurance charges entered. Optionally, the claims may be transmitted electronically to participating insurance companies and agencIes. 4. Print, stuff, and mail private statements (monthly). 5. Production of monthly reports and delivery to the City. Selection of reports to be mutually agreed upon based on the current reports available in the Systems Design Northwest, Inc. MMS software. 6. Collection procedures as approved by the City. Page 1 of 4 7. Review all accounts and rebilllfollow-up as necessary. 8. Deposit all payments mailed to Systems Design Northwest, Inc. in an account specified by the City no less than weekly or when the total ofthe checks on hand reaches $2,500.00. The City shall have sole control over this account with Systems Design Northwest, Inc. having deposit only access. Copies of all deposit slips will be forwarded directly to the City. 9. Systems Design Northwest, Inc. shall investigate the feasibility of electronic remittance. If it is mutually determined to be in its best interest of the City, Systems Design Northwest, Inc. shall implement electronic remittance from major insurance carriers. 10. Provide customer service via toll free phone lines for all patient billing questions, Monday through Friday, 8:00 a.m. to 5:00 p.m. (Federal holidays excepted). 11. Provide all necessary supplies including insurance forms, private statements, envelopes and backup diskettes. ARTICLE IT - TERM AND TERMINATION OF THE AGREEMENT This Agreement shall be for ambulance transports occurring between July 25, 2003 through December 31, 2004. This Agreement may be renewed for additional terms upon the mutual agreement of both parties. This Agreement may be terminated by either party upon 30 days written notice to the other party at the address below. Upon termination ofthis Agreement, Systems Design Northwest, Inc. shall provide follow-up private billings and payment posting as necessary for a period of one additional month. Within 30 days of this additional month of service, Systems Design Northwest, Inc. shall return all materials, medical incident reports, and other documentation provided to it by the City under this Agreement. Systems Design Northwest, Inc. shall also provide a detail report of the current status of all outstanding accounts. ARTICLE III - PAYMENT FOR SERVICES Systems Design Northwest, Inc. shall submit a bill to the City on a monthly basis for services provided. The amount of the bill shall be calculated as the total of: A. $20.00 for each MIR entered during the current billing period. B. 50% of receipts received for all resident transports and ambulance services provided prior to July 25,2003 (disposable equipment fee only) . C. Actual postage expenses. Page 2 of 4 Payment by the City to Systems Design Northwest, Inc. shall be made within 30 days of receipt of such billing. Upon renewal of this Agreement for additional terms, the rate used in the above calculation may be adjusted to a new rate as mutually agreed. ARTICLE IV - CONFIDENTIALITY Systems Design Northwest, Inc. shall not release any information provided to it under this Agreement to any source, provided however, that it may release information (including copies of MIRs) as required by insurance companies or agencies to facilitate payment for claims submitted. ARTICLE V - INDEMNIFICATION / HOLD HARMLESS Systems Design Northwest, Inc. shall defend, indemnify and hold the City, its officers, officials, employees and volunteers harmless from any and all claims, injuries, damages, losses or suits including attorney fees, arising out of or in connection with the performance of this Agreement, except for injuries and damages caused by the sole negligence of the City. The City shall defend, indemnify and hold Systems Design Northwest, Inc., its officers, officials, employees and volunteers harmless from any and all claims, injuries, damages, losses or suits including attorney fees, arising out of or in connection with the performance of this Agreement, except for injuries and damages caused by the sole negligence of Systems Design Northwest, Inc. ARTICLE VI - INSURANCE Systems Design Northwest, Inc. shall obtain and maintain professional liability insurance with limits no less than $1,000,000 per claim and shall forward the City a certificate of insurance so verifying. ARTICLE vn - MISCELLANEOUS This Agreement may be modified or amended only in writing and signed by each of the parties. This Agreement is to be governed and construed under the laws ofthe State of Washington. This Agreement contains the entire agreement between the City and Systems Design Northwest, Inc. with respect to the subject matter of this Agreement. All prior arrangements or undertakings are superseded by this Agreement. In the case anyone or more provisions contained in this Agreement shall be determined to be invalid, illegal or unenforceable in any respect, the remaining provisions contained herein shall not in any way be affected or impaired thereby. The tolerance of a breach or default under this Agreement shall not be construed to be a waiver of such breach or default. Page 3 of 4 All notices hereunder by either party to the other shall be in writing. All notices, demands and requests shall be deemed given when mailed, postage prepaid, registered or certified mail, return receipt requested to the address below. City of Port Angeles POBox 1150 Port Angeles, W A 98362 ~ ;t2.;.~ City Manager OW~ Systems Design Northwest, Inc. POBox 3510 Silverdale, W A 98383-3510 fIG s esign Northwest, Inc. /0--3-2003 Date Fire Chief APP&t~<7 ~ City Attorney\. q /3u/c; 3 I I Date Page 4 of 4