A: Service Provider Agreement DHHS (DSS-9)

Appendix A
DSS-9

Agreement Number ________________

SECTION I
Check Appropriate Box and Write Provider Number
Agency FID __________________	Individual Provider Social Security Number __________________________________
SECTION II
Provider Name ____________________________________________________________
Provider Street Address ____________________________________________________________
Mailing Address if Different from Location		___________________________ ___________________________
Business Telephone _____________________________		Home Telephone ___________________________
Appropriate Licensure ___________________________________________________________
Location of Service Provision if different than above ___________________________________________________________

Par. 1 This Agreement between the Nebraska Department of Health and Human Services (hereinafter the Department) and ____________________________, a service provider, governs the provision of the following service(s) checked below as defined in the Department of Health and Human Services Program Manual, Nebraska Administrative Code (NAC) Titles 465, 471, 473, 474, and 480. Appropriate checklist(s) marked "Provider Addendum (name of service)" and other appropriate additions to the agreement marked "Attachment (A,B, or C)" for contracted service is/are attached and by this reference are made part of this agreement as if included in the contract word for word and the provider agrees to abide by all regulations as outlined in the attachment(s).

Par. 2 Agreement Effective Date from ____________ through _____________.

Par. 3 Service(s) to be provided. (See corresponding service addendum.) DD = Developmental Disabilities

SECTION III

Terms of Agreement

Par. 1 If the provider violates or breaches any of the provisions of this Agreement, then this Agreement may be terminated immediately, at the election of the Department. If there are any damages arising from such violation or breach, legal remedies may be pursued to recover such damages. Any money due to the provider which accrued prior to such violation or breach may be offset against the damages.

Par. 2 Under the terms of this Agreement:

The service area staff will determine eligibility for services and authorize appropriate services for the individuals.
The service area staff will notify providers if the service(s) being provided for a specific client is to be terminated or changed before the end of the authorized period.
The Department will honor claims and make payments for services that were authorized and provided in accordance with the Department's policies and standards.

Par. 3 This Agreement may be terminated by either party at any time by giving at least thirty days advance written notice to the other party to allow for arrangements of alternate service provision for service clients. The notice requirement may be waived in case of emergencies such as illness, death, injury, or fire. Only such payments as have already accrued for services rendered prior to the effective date of termination shall be made to the provider upon such voluntary termination.

Par. 4 Subcontracting by an individual provider is not allowed under this Agreement.

DSS-9 Rev. 3/98 (05004)
(Previous version 4/96 should NOT be used)

Par. 5 Service(s) will be provided using the following unit rate(s) within the maximum number of units authorized by the service area staff on a case-by-case basis. This information applies to all services covered by this agreement except Personal Care Aide (see below), and Child Care.

Service Code	Service	Maximum Rate	Units

Medicaid Personal Care Aides are authorized as follows:
Procedure Code	Service	Rate
199814	Trained PCA*	______________
199811	Service - Untrained PCA	______________
* Attach documentation of trained status

SECTION IV

General Provider Standards
By signing this agreement, the service provider agrees to:

Follow all applicable Nebraska Health and Human Services policies and procedures (Nebraska Administrative Code Titles 465, 471, 473, 474, and 480).
1. Bill only for services which are authorized and actually provided.
2. Submit billing documents after service is provided and within 90 days.
Accept payment as payment in full (payment from DHHS plus the client's obligation) and assure that the rate negotiated or charged does not exceed the amount charged to private payers.
Not provide services if s/he is the legally responsible relative (i.e., spouse of client or parent of minor child who is a client).
Not discriminate against any employee, applicant for employment, or program participate or applicant because of race, age, color, religion, sex, handicap, or national origin, in accordance with 45 CFR Parts 80, 84, 90; and 41 CFR Part 60.
Retain financial and statistical records for four years from date of service provision to support and document all claims.
Allow federal, state, or local offices responsible for program administration or audit to review service records, in accordance with 45 CFR 74.20-74.24; and 42 CFR 431.107. Inspections, reviews, and audits may be conducted on site.
Keep current any state or local license/certification required for service provision.
Provide services as an independent contractor, if the provider is an individual, recognizing that s/he is not an employee of the Department or of the State.
Agree and assure that any false claims (including claims submitted electronically), statement, documents, or concealment of material fact may be prosecuted under applicable state or federal laws (42 CFR 455.18).
Respect every client's right to confidentiality and safeguard confidential information.
Understand and accept responsibility for the client's safety and property.
Not transfer this agreement to any other entity or person.
Operate a drug free workplace.
Not use any federal funds received to influence agency or congressional staff.
Not engage in or have any ongoing history of criminal activity that may be harmful or may endanger individuals for whom s/he provides services. This may include a substantiated listing as a perpetrator on the child and/or adult central registries of abuse and neglect.
Allow Central Registry checks on himself/herself, family member if appropriate, or if an agency, agree to allow Department of Health and Human Services staff to review agency policies regarding hiring and reporting to ensure that appropriate procedures regarding abuse, neglect, and law violations are in place.
Have the knowledge, experience and/or skills necessary to perform the task(s).
Report changes to appropriate Department staff (e.g., no longer able/willing to provide service, changes in client function).
Agree and assure that any suspected abuse or neglect will be reported to law enforcement and/or appropriate Department staff.

I certify that I have read and understand the standards as stated and referenced above and agree to comply with all the terms of this Agreement.

SECTION V

____________________________________ ___________
Provider/Agency Representative Date

____________________________________ ___________
Parent or Legal Guardian Signature (if required) Date

____________________________________ ___________
Signature of Authorized Representative Date
Nebraska Department of Health and Human Services

Posted January 25th, 2008

Adult Day Care	Habilitative Day Care - DD	Independence Skills Man.
Adult Day Health	Homemaker	Nutrition Services
Assisted Living	Homemaker - DD	PERS
Child Care	Home Care/Chore	Personal Care Aid - Medicaid
Congregate Meals	Home Delivered Meals	Respite Care
Family Support	Home Modifications DD	Transportation