APPLICANT PROPOSAL For Non-Emergency Medical Transportation (NEMT) Coordination Services

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1 1 APPLICANT PROPOSAL For Non-Emergency Medical Transportation (NEMT) Coordination Services INSTRUCTIONS: If you want to be considered to provide services in response to the Request for Proposals for NEMT Coordination by Stearns County Department of Human Services, please complete this Proposal in the format provided below. Please write directly on this document and use additional paper when required to provide complete information, but do not send additional documentation not requested as part of this proposal. Return the original plus five (5) copies of the proposal. I. GENERAL INFORMATION Business Name: Business Address: Home Office Address (if different from business address): Business Telephone: Business Fax: Contact Person and Title: Name and Title of Person Authorized to sign a Contract for Your Business: II. ORGANIZATIONAL STRUCTURE A. Please identify your organizational status: Sole Proprietorship Partnership For Profit Corporation Non-Profit Corporation LLC Other (specify) B. If you are a partnership identify all partners:

2 2 C. If you are incorporated or organized as an LLC provide your articles of incorporation or organization, bylaws, names of current directors, organizers, members and officers. D. Provide a complete organizational chart for your organization. E. Provide a description of your organization: its history, capacity, number of employees, vision, goals and philosophy of service. III. INSURANCE & OTHER REQUIREMENTS Provide proof of insurance and other requirements listed in Lead County Contact Prerequisites, Attachment A. IV. PROPOSED SERVICE(S): A. Executive Summary: Provide a brief (less than 3 pages) summary of the services you propose to provide for Stearns County clients. B. Proposed Statement of Work: Provide a detailed description of how you would provide NEMT coordination services in Stearns County. At a minimum include how you would: Market and inform stakeholders and clients of an NEMT coordination system in Stearns County Establish and maintain a call center including service during business hours and afterhours service. Include procedures used to report numbers, trends and disposition of calls to County on a regular basis. Handle incoming inquiries for NEMT including screening, determination of eligibility, handling of emergency requests, verification of participation in a fee for service plan, etc. Also include procedures to provide information to callers regarding services, grievances, rights and responsibilities. Determine the most appropriate and cost-effective type of transportation service given the client s level of mobility and functional independence. How would you determine if the client has any special needs that would influence the type of transportation provided? Arrange and schedule NEMT rides, including rides that are outside of Stearns County, outside of state, require air transport or the use of a stretcher. Also include procedures for providing lodging and meals when required. Establish and maintain an adequate transportation provider network. Include a model service agreement/contract between your organization and a transportation provider. Include any volunteer driver networks and public transportation. Do you provide

3 3 assistance to your provider network to remain in compliance with requirements? How do you monitor compliance and what are your procedures for non-compliance? Schedule rides for clients in a cost effective manner, while adhering to a reasonable pick-up and delivery schedule for clients. Obtain reimbursement for services from the Minnesota Department of Human Services and assume responsibility for unclaimable transportation costs Monitor fraud, waste and abuse of transportation services and employ corrective action when needed. Reimburse clients for eligible health care access costs incurred such as mileage and other travel expense. Handle unexpected circumstances such as last minute cancellations, last minute requests for transportation, no-shows, changes in conditions, etc. Store records pertaining to an NEMT contract with Stearns County according to applicable state and federal requirements. Provide your procedures for investigating complaints and incidents related to the provision of NEMT services. C. List contracts you have in place for the provision of transportation services with other public or private entities. What are your expectations of transportation providers with whom you contract? D. Have any of your contracts with public entities been terminated or not renewed? If so, provide details. E. Provide a full description of the computer software and hardware you use for transportation coordination. Include claiming and billing, verifying eligibility, fraud prevention, handling/tracking calls, record storage, reporting to County and other entities, etc. F. Do you have expectations of County as a contracted entity regarding the provision of NEMT coordination? If so, please explain. G. Provide a copy of your organization s policies and procedures for NEMT coordination. H. Provide training materials used when hiring staff for NEMT coordination. I. Provide a sample report that you would provide to County detailing calls received and disposition of those calls, trips assigned, requests denied, complaints and disposition of complaints, trends and performance.

4 4 VI. BUDGET: Attach a budget for your proposed services to Stearns County for one year. VII. RATES: Provide proposed rates for services for Stearns County for each type of trip coordinated including one-way trips, client reimbursement, bus passes, volunteer driver rides, air and other special circumstances

5 5 VII. FINANCIAL RESPONSIBILITY Please answer the following questions. For purposes of this Section VII., the term you shall mean and include all partners, officers and directors, if any. A. Are your financial books and records audited by an independent accounting service? If Yes, please attach a copy of your most recent audit and management letter. B. Are all of your state and federal tax obligations, including payroll and income taxes, current? If No, please describe: Yes No C. If you have access to or responsibility for safeguarding client funds, please describe how you do so. If you do not have such access or responsibility, please so indicate. D. Are you presently debarred, suspended, ineligible or excluded from transacting business by or with any federal, state or local governmental department or agency? E. Within the past six years, have you been convicted of or had a civil judgment rendered against you for the commission of fraud or any criminal offense in connection with obtaining or performing a public contract? F. Within the past six years, have you been adjudicated a bankrupt or filed for relief in the United States Bankruptcy Court? G. Within the past six years, have you been or are you presently a party to a lawsuit or administrative proceeding related to the ownership and operation of your business? H. If you answered Yes to any of Questions D., E., F. or G., above, please describe (Use additional paper if required):

6 6 VIII. FINANCIAL MANAGEMENT AND INTERNAL CONTROL Check the appropriate answer to each Question. If the response is No, please explain in the Comments section. (Attach additional sheets, if necessary) Is there a formal accounting structure with chart of accounts established? Are accounting procedures reviewed at least annually and revised as necessary? Is there monthly monitoring of planned versus actual expense and obligation of funds to determine balances and possible overspending? Are numerical sequences of pre-numbered documents accounted for? Is it prohibited to issue checks to cash or bearer? Is it prohibited to sign checks in advance? Are disbursements, except those from petty cash, made by check? Are bank statements reconciled on a monthly basis? Are there policies or written documentation designating which individuals are authorized to sign time and attendance reports, etc.? Complete the following questions if you employ staff: Are accounting policies and procedures easily accessible by those required to follow those policies and procedures? Are there measures in place limiting unauthorized personnel from storage areas of such things as inventory, petty cash, blank checks, voided checks, etc.? Are employees who are authorized to deal with company funds bonded? Is it identified in writing who is authorized to sign checks and/or use signature stamp and/or complete wire transfers? Are all tax payments current, i.e. payroll taxes, sales tax, income taxes, Social Security, FICA,? Are all insurance premium payments current, including workman s compensation insurance premiums? Is the incoming mail opened by someone other than the person(s) having access to cash receipts or accounts receivable records? Are authorized check signers independent of check preparation, cash receiving and petty cash. Are bank reconciliations completed by someone other than persons participating in the receipt or disbursement of cash or those authorized to issue checks or handle cash. YES NO COMMENTS

7 7 CERTIFICATION I hereby certify that each answer set forth on this Applicant Proposal and all other information I have furnished is true and correct. I certify that I have the authority to submit this Proposal on behalf of the entity named herein. Dated: (Signature and Title) STEARNS COUNTY DEPARTMENT OF HUMAN SERVICES RESERVES THE RIGHT TO REQUIRE ADDITIONAL INFORMATION. SUBMISSION OF THIS PROPOSAL DOES NOT GUARANTEE A CONTRACT WITH STEARNS COUNTY.

8 8 LEAD COUNTY CONTRACT PREREQUISITES Attachment A As part of establishing a Lead County Contract a vendor must submit certain documents. These documents include but will not necessarily be limited to: 1) Proof of current insurance.* a) General liability covering an amount not less than $1,500,000 per occurrence. b) Professional liability covering personnel for the following amounts: $1,500,000 per occurrence if applicable. d) Workers Compensation Insurance as required by Minnesota state law including a certificate of compliance pursuant to Minnesota Statute e) Unemployment Compensation Insurance as required by law. 2) Proof of payment of all due taxes, penalties and interests. 3) Proof that person signing contract has authorization to execute contracts. * Stearns County must be covered as an additional insured by a vendor s general and professional liability insurance, in the amounts indicated above. Also, a standard indemnification clause will be part of the contract.

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