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Rate Enhancement Affidavit

The individuals whose signatures are set forth below represent and warrant that they are duly empowered to execute this affidavit.  Affiant represents and warrants that it has all legal authority to respond on behalf of and to bind the Participating Provider to the terms of the Affidavit. A material or false statement or omission made in connection with this affidavit may subject the person and/or entity making the false statement to any and all criminal penalties available pursuant to applicable Federal and Texas state law.

Definitions:
Participating Provider: A provider who is contracted with Superior HealthPlan.
Rate Enhancement: An additional amount of monies paid to a provider to be passed on for compensation of direct care staff.

Only participating providers who are enrolled in the State of Texas Medicaid Program are eligible to participate in Superior HealthPlan’s Rate Enhancement Program. 

I, 

swear an oath under penalty of law that I am the

and that the statements submitted in this affidavit are true and correct to the best of my knowledge.

I further swear that I or my company have met the requirements set forth in 15 TAC §355.112 which states that allowable enhancement fund compensation for attendants (as defined above) was applied either as salaries and/or wages, including payroll taxes and workers’ compensation, or employee benefits to direct care staff.

I agree to submit to an audit, examination and review of books, records, documents and files, in whatever form they exist, of the named company and its affiliates, inspection of its places(s) of business and equipment, and to permit interviews of principals, agents, and employees. I understand that refusal to permit such inquiries shall be grounds for whatever civil and criminal penalties are available pursuant to applicable federal and state law and/or termination of my contract with Superior HealthPlan, Inc.

Should an audit result in a finding of non-compliance with these requirements, it could result in recoupment of those enhanced payments and termination of the contract with Superior HealthPlan. It shall also be grounds for whatever civil and criminal penalties are available pursuant to federal and state law.

To prevent any delay in processing, it is very important to include the following information on the returned affidavit: Tax Identification Number (TIN), your assigned National Provider Identifier (NPI) number and the nine digit HHSC contract number awarded to you from the Texas Health and Human Services (not to be confused with your HHSC five-to-six digit license number).

Numeric Values Only

 


The following programs are eligible for Rate Enhancement: Primary Home Care (PHC), Day Activity and Health Services (DAHS), and Assisted Living. Please select the program type and enter in your HHSC Contract ID and Billing NPI or Atypical ID.

Please note: If you have never contracted with HHSC, you can enter 000000000 in lieu of the contract ID.
Add an Additional Program Type
Please note: If you have never contracted with HHSC, you can enter 000000000 in lieu of the contract ID.
Please note: If you have never contracted with HHSC, you can enter 000000000 in lieu of the contract ID.
Please note: If you have never contracted with HHSC, you can enter 000000000 in lieu of the contract ID.
Please note: If you have never contracted with HHSC, you can enter 000000000 in lieu of the contract ID.
Please note: If you have never contracted with HHSC, you can enter 000000000 in lieu of the contract ID.
Please note: If you have never contracted with HHSC, you can enter 000000000 in lieu of the contract ID.
Please note: If you have never contracted with HHSC, you can enter 000000000 in lieu of the contract ID.
Please note: If you have never contracted with HHSC, you can enter 000000000 in lieu of the contract ID.
Please note: If you have never contracted with HHSC, you can enter 000000000 in lieu of the contract ID.
Please type your full name.
Numeric Values Only

Please Note: For your records, a copy of this submission will be sent to the affiant's email address provided above.

Please complete and mail in your form per instructions, no later than October 30, 2019.