1. 1 Kentucky Women’s Cancer Screening Program Local Health Department Individual Provider Contract Training April 21, 2016

2. CONTRACT RATE SHEET Contracted Provider Name_______________________ Local Health Dept. Name________________________ KENTUCKY WOMEN’S CANCER SCREENING PROGRAM NEGOTIATED RATE SHEET

3. 3 CONTRACT RATE SHEET (Cont.) The rate list should only include the CPT codes that will be reimbursed to this contracted provider by the LHD. Use multiple copies of this form for additional codes. The link below will take you to the current version of the Core Clinical Service Guide (CCSG). The Cancer Screening/Follow-Up Section, found in the CCSG, is to be utilized by the provider when providing services to cancer screening patients referred by the LHD. http://chfs.ky.gov/dph/CCSG+2015.htm

4. 4 CHANGES/ADDITIONS IN BODY OF CONTRACT If a LHD adds additional language or information to the body of a contract outside of the template form, the LHD will be responsible for those additions and/or changes. Changes may be made that require additional services from a provider but they must at least cover the minimum requirements listed in the CCSG Cancer Screening Follow-Up Section.

5. 5 LAB/PATHOLOGY 8814188305 8814288307 8814388331 8816488332 8816588341 8817388342 8817487624 8817587625 88172

6. 6 BREAST SURGEON 10021190821910119283 10022190831912019284 19000190841912519285 19001190851912619286 19081190861928119287 191001928219288 Also evaluation/management and preventative codes 99201-99396 (except for 99215) and 99420

7. 7 GYNECOLOGICAL SERVICES 574525746057520 574545746157522 574555750058100 574565750558110 Also evaluation/management and preventative codes 99201-99396, (except for 99215)

8. 8 RADIOLOGIST 7609877055 7664177056 7664277057 7694277058 7705377059 G0202G0204 G0206

9. 9 ANESTHESIOLOGIST 00400

10. 10 BILLING FOR PROCEDURES PERFORMED IN HOSPITALS If the hospital employs the surgeons and anesthesiologists and pays their salaries, the hospital may bill for the services that these providers perform. The individual providers shall not be allowed to bill separately. When lab specimens are evaluated at the hospital lab instead of being sent out, the hospital may bill for these services. Only one provider may bill for each service. The LHD will need to determine whether it should be the hospital or the provider by discussing their arrangements at contract negotiation time.

11. 11 PROCEDURES THAT MAY BE PAID WITH OTHER FUNDS BUT CANNOT BE REIMBURSED WITH FEDERAL KWCSP FUNDS 0094088104 1903099215 77052W9215 77054W0166

12. 12 QUESTIONS

13. 13 CONTACT INFORMATION Melody.Stafford@ky.gov 502-564-3236 x 4159 Sivaram Maratha, Data Manager SivaramR.Maratha@ky.gov 502-564-3236 x 4161 Regina Reid, Quality Assurance Consultant, Western Kentucky Regina.Reid@ky.gov 270-404-1215 Christina Marraccini, Recruitment Coordinator Christina.Marraccini@ky.gov 502-564-3236 x 4156