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NEW YORK STATE (New York State)

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NEW YORK STATE
DEPARTMENT OF HEALTH
AIDS INSTITUTE
Pre- Exposure Prophylaxis Assistance Program
(PrEP-AP)
SPECIALTY PROVIDER AGREEMENT
518-459-1641
EMPIRE STATION
P.O. BOX 2052
ALBANY, NEW YORK
12220-0052
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NEW YORK STATE DEPARTMENT OF HEALTH/AIDS INSTITUTE
HIV UNINSURED CARE PROGRAMS
Specialty Agreement to support the use of HIV Pre-exposure Prophylaxis, or PrEP
through approved New York State Article 28 Providers
This Agreement signed today, sets forth the terms and conditions governing participation in the
New York State Department of Health, AIDS Institute Pre-Exposure Prophylaxis Assistance
Program, (the “Program”) administered by Health Research, Inc. (hereinafter referred to as HRI)
in cooperation with the New York State Department of Health, AIDS Institute (hereinafter
referred to as the “AIDS Institute”) as a “specialty provider”.
BACKGROUND
Pre-Exposure Prophylaxis (PrEP) is an HIV prevention method in which people who do not have
HIV take a daily pill to reduce their risk of becoming infected. Based on studies showing
significant reduction in HIV acquisition among HIV-negative persons who use PrEP and receive
a package of prevention, care and support services, the U.S. FDA approved combination anti-
retroviral therapy (ART) for use as PrEP among sexually active adults at risk for HIV infection.
A detailed description of the guidelines for the use of Pre-Exposure Prophylaxis (PrEP) to
prevent HIV transmission can be found at: http://www.hivguidelines.org
REIMBURSABLE SERVICES UNDER PrEP-AP
The services reimbursable under PrEP-AP include the following medical services, provided on
an out-patient ambulatory basis. PrEP-AP uses established fee for service Medicaid rate
schedules and coding for payment of covered services. No co-payment can be charged to
participants. As a PrEP-AP participating provider, you agree to provide your patients with the
following services:
1. Initial Pre-Prescription Education and Evaluation – Must include the following
elements; evaluation and education for the patient regarding the risks, benefits, and
options of PrEP. This education includes:
How PrEP works as part of a comprehensive prevention plan;
The limitations of PrEP;
PrEP use, including dosing and adherence;
Information regarding prevention of the transmission of HCV infection;
Common side effects;
The long-term safety of PrEP;
Baseline tests and the schedule for monitoring;
The criteria for discontinuing PrEP;
The possible symptoms of seroconversion;
For women, the potential benefits/risks if pregnancy occurs during use of PrEP;
Perform laboratory tests (reporting of the test results to the patient):
o Baseline HIV Test
Third-generation and fourth-generation HIV test
Nucleic acid amplification test (NAAT, viral load) for HIV for:
Patient with symptoms of acute infection
Patients whose antibody test is negative but who have
reported unprotected sex with an HIV-infected partner in
the last month
o Basic Metabolic Panel
o Urinalysis
o Serology for Viral Hepatitis A, B, C
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o Screening for Sexually Transmitted Infections (NAAT for gonococcal and
chlamydia infection-3 site screening (genital, rectal, pharyngeal)
o Pregnancy Test
2. Prescribing and Monitoring PrEP
Lab report and Prescription visit:
o Write a 30 day prescription of Truvada (TDF/FTC), one tablet daily to
begin when patient has a confirmed negative HIV test result
30-day visit:
o Assess side effects
o Serum creatinine and calculated creatinine clearance for patients with
borderline renal function or at increased risk for kidney disease (>65
years of age, black race, hypertension, or diabetes)
o Discuss risk reduction and provide condoms
o Provide a 90 day prescription
3-month visit:
o HIV test
o Ask about STI symptoms
o Discuss risk reduction and provide condoms
o Serum creatinine and calculated creatinine clearance
o Pregnancy test
6-month visit:
o HIV test
o Obtain STI screening tests
o Pregnancy test
o Discuss risk reduction and provide condoms
9-month visit:
o HIV test
o Ask about STI symptoms
o Discuss risk reduction and provide condoms
o Serum creatinine and calculated creatinine clearance
o Pregnancy test
12-month visit:
o HIV test
o Obtain STI screening tests
o HCV serology for MSM, IDUs and those with multiple sexual partners
o Pregnancy test
o Urinalysis
o Discuss risk reduction and provide condoms
3. Discontinuation of PrEP Regimen
PrEP should be discontinued and the participant terminated from PrEP-AP if the patient:
Receives a positive HIV test result
Develops renal disease
Is non-adherent to medication or appointments after attempts to improve adherence
Is using medication for purposes other than intended
Reduced risk behaviors to the extent that PrEP is no longer needed
Requests discontinuation with referral to risk reduction support services and
documentation of referral
Note: For women who become pregnant while using PrEP, continuation of PrEP during
pregnancy is an individualized decision based on whether there are ongoing risks for
HIV during pregnancy.
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The approved Provider agrees to be legally bound to the following:
1. Provider’s RESPONSIBILITIES:
A. The Provider agrees to participate in the Program and to comply with all Federal and New
York State laws generally and specifically governing participation in the Medicaid Programs.
The Provider agrees to be knowledgeable of and to comply with applicable rules, regulations
rates and fee schedules promulgated under such laws and any amendment; thereto. The
Provider further certifies that it has all licenses, certifications and regulatory clearances
required under State and Federal law and/or regulation to perform the services to be
reimbursed hereunder, and that it is legally qualified in all aspects to perform such services.
B. The submission by or on behalf of the Provider of any claim for payment under the Program
shall constitute certification by the Provider that:
1. the services or items for which payment is claimed was actually provided by the Provider
to the PrEP-AP member(s); and
C. The Provider will accept payment from HRI as payment in full and will not seek additional
reimbursement from PrEP-AP members.
D. The Provider agrees to prepare and maintain contemporaneous records demonstrating its
right to receive payment under the Program and to keep for a period of six years from the
date of service all information regarding claims for payment submitted by or on behalf of, the
Provider and to furnish such records and information, upon request, to the New York State
Department of Health (NYSDOH), HRI and its agents and/or designees.
E. The Provider will not discriminate in its provision of services reimbursed under this
Agreement based on any non-merit factor, including race, national origin, color, religion, sex,
sexual orientation, gender identity, disability (physical or mental), age, status as a parent, or
genetic information. The Provider has an affirmative duty to take prompt, effective,
investigative and remedial action where it has actual or constructive notice of discrimination
in the terms, conditions or privileges of provision of services to a member or potential
member hereunder based on the factors listed above.
F. The Provider will permit audits of claims made under this Program. Such audits may be
performed by the Federal Government, NYSDOH, HRI and/or their representative.
G. The Provider will submit claims for payment on officially authorized claim forms or other
acceptable methods approved by the Program. All such payments shall be subject to
correction and adjustment upon audit under Paragraph (F) above.
H. The Provider certifies payment made by HRI under this Agreement shall not duplicate
reimbursement of costs or services provided pursuant to this agreement that are received
from other sources including, but not limited to client fees, private insurance, public
donations, grant, or legislative funding from other units of government of any other source.
I. Provider represents that the information submitted in or with the application for enrollment to
participate in the Program and from which this Agreement ensued is true, accurate and
complete. The Provider agrees further that such representation shall be a continuing one
and that the Provider shall notify HRI (in writing within fifteen (15)) days of its occurrence, if
any fact arises or is discovered subsequent to the date of the application which affects the
truth accuracy or completeness of such representation.
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J. Provider agrees that it shall not claim or assert any proprietary interest in any of the data or
materials produced or delivered by the Provider in the performance of the covered services
reimbursed hereunder. The Provider shall not infringe upon any copyright, trademark,
patent, statutory or other proprietary rights of others and will hold harmless HRI, the New
York State Department of Health and the State of New York from any costs, expenses, and
damages resulting from any breach of this warranty.
K. Provider agrees to indemnify and hold harmless HRI, the New York State Department of
Health and State of New York from and against any and all claims of any third parties for
damage and expenses of whatsoever nature arising from growing out of, or related to the
Provider’s negligence or sole failure to perform any and all services reimbursed under the
Agreement.
L. The Provider, its officers, agents and employees and subcontractors shall treat all
client/patient information, which is obtained by it through its performance under this
Agreement, as confidential information to the extent required by the laws and regulations of
the United States and laws and regulations of the State of New York.
M. The Provider is a corporation authorized to expend funds for any loss, claim, action or
judgment. The Provider will defend, settle, and without limitation satisfy any judgment
against it in connection with claims and/or litigation filed against it.
2. ADDITIONAL TERMS
A. The effective date of the agreement is _______________ and shall remain in effect until
terminated in accordance with this Agreement. Termination of the agreement shall not
relieve the restitution of overpayment for services or items made prior to termination in
accordance with paragraphs 1. (C) and 1. (G).
B. It is understood that either the Provider or HRI by giving 30 days written notice, may
terminate this Agreement. It is understood and agreed, however, that in the event that the
Provider is in default upon any of its obligations here under at the time of such termination
such right of termination on the part of HRI shall expressly be in addition to any other rights
or remedies which HRI may have against the Provider by reason of such default.
C. HRI may terminate this Agreement at any time. HRI may honor claims for services properly
submitted within 90 days of such approved services, which in its judgment arose from
services rendered by Provider prior to the date of termination by HRI.
D. This Agreement shall not be construed to contain any authority, either, express or implied,
enabling the Provider to incur any expense or perform any act on behalf of HRI and/or
Program.
Provider Commitment:
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MMIS Provider Number:
Provider Type:
NPI Number:
Tax ID Number:
-
Facility Name:
MMIS Locator Code:
Address:
City:
State:
Zip Code:
Main Phone:
(
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Ext:
Patient Phone:
(
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Ext:
Administrative Contact:
Title:
Email:
Phone:
(
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Clinical Contact:
Title:
Email:
Phone:
(
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Fiscal Contact:
Title:
Email:
Phone:
(
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Billing Address (if different from above):
Facility
Name:
Address:
City:
State:
Zip Code:
Phone:
(
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Ext:
Claims Processing Clearing House Information
Emdeon: Payer ID: 14142 - Payer Name: NYS DOH UCP
New York State Department of Health
UNINSURED CARE PROGRAMS
Empire Station .PO BOX 2052 . Albany, NY 12220
Phone: 1-800-542-2437 Fax: 518-459-2749
Pre-Exposure Prophylaxis
Assistance Program
Specialty Provider Enrollment Form
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Make additional copies of this form to include all Locator Codes for this Facility:
ADDITIONAL LOCATIONS FOR THIS FACILITY:
MMIS Locator Code:
Facility Name:
Address:
City:
State:
Zip Code:
Main Phone:
)
-
Ext:
Patient Phone:
)
-
Ext:
MMIS Locator Code:
Facility Name:
Address:
City:
State:
Zip Code:
Main Phone:
)
-
Ext:
Patient Phone:
)
-
Ext:
MMIS Locator Code:
Facility Name:
Address:
City:
State:
Zip Code:
Main Phone:
)
-
Ext:
Patient Phone:
)
-
Ext:
MMIS Locator Code:
Facility Name:
Address:
City:
State:
Zip Code:
Main Phone:
)
-
Ext:
Patient Phone:
)
-
Ext:
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Completed 14 August 2020

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