A Service Agreement is required for the following services:  Job Coaching, Job Coaching/Placement, Job Coaching/Interpreting, Job Readiness Training, Work Site Skills Trainer, Self-Employment Consultation, Business Plan Implementation/Revision, Interpreter—Foreign Language, Interpreter – Deaf or Hard of Hearing, Benefits Assessment, Benefits Planning, Benefits-PASS Development, Benefits Management, Rehab Technology – Rehab Engineering, Independent Living Training, Individual Supported Employment, and Customized Employment.  

Background checks for specific types of providers are required prior to the provision of services unless the Exception Process is followed.

1. A VR Office Director or the VR Director may develop a Service Agreement when:

• there is an identified need for specific types of services in the area and prospective providers are invited to discuss the need (including service description, projected number/characteristics of the population needing the service, etc.)
• a service provider contacts a VR office to seek a Service Agreement with VR
• an Independent Provider seeks a Service Agreement with VR. An Independent Provider is a person who is enrolled as a Medicaid provider by Department of Health and Human Services’ (DHHS) contractor, Maximus, to provide services authorized by the Division of Developmental Disabilities (DDD). Note that an Independent Provider may deliver only Individual Supported or Customized Employment services for people with Intellectual/Developmental Disabilities (I/DD) under a Service Agreement with VR. A Service Agreement with an Independent Provider is permitted only so long as the Independent Provider maintains their Medicaid provider enrollment status

2. Identify the services to be provided.  A Service Agreement is required for these services:

• Job Coaching
• Job Coaching/Placement
• Job Coaching/Interpreting
• Job Readiness Training
• Work Site Skills Trainer
• Self-Employment Consultation
• Business Plan Implementation/Revision
• Interpreter/Foreign Language
• Interpreter – Deaf or Hard of Hearing
• Benefits Assessment
• Benefits Planning
• Benefits – PASS Development
• Benefits Management
• Rehab Technology – Rehab Engineering
• Independent Living Training
• Individual Supported Employment (SE), with type specified
• Customized Employment (CE), with type specified

3. If the prospective provider will provide Individual Supported Employment or Customized Employment Services (SE/CE), VR will check to ensure they are properly credentialed, as follows:

• A provider of Behavioral Health Supported Employment must be a Department of Behavioral Health (DBH)-approved provider and have an agreement with the Regional Behavioral Health authority
• An agency provider of I/DD Supported Employment or Customized Employment must be certified to provide Supported Employment by the DDD.  The list of agency providers and the services they are certified to provide can be found at: http://dhhs.ne.gov/developmental_disabilities/Documents/ProviderAgencyList.pdf
• An Independent Provider must be enrolled as a Medicaid Provider and prior-approved by DDD to provide services to an individual.  This is verified by obtaining the provider’s Medicaid provider number. In addition, an Independent Provider must meet the General Qualifications outlined in the Service Agreement as determined by the Office Director and complete additional background checks outlined in the VR Service Agreement .

4. If the prospective provider must be licensed or certified in his or her profession (such as when providing interpreter or benefits services) obtain certification and/or licensure documentation, as needed.  (Note that in the case of the Benefits services an agency will ensure on-going licensure or certification of its staff.) Documentation should be current and the expiration date of the license or certification noted for entry into QE2.    

5. Completion of Service Agreement:

• The prospective provider completes the top section of the Service Agreement including name and identifying information, and answers the questions about whether the entity employs persons who will provide direct services and whether the named entity will directly provide services.
• VR Office Director/VR Director fills in effective dates and determines whether the prospective provider is an Independent Provider and whether mileage will be paid.  Note:  Mileage is already included in some rates, including those for Supported and Customized Employment.
• If the ‘yes’ box is checked for Independent Provider, obtain the person’s Medicaid Provider Number and write it in the space provided. 
• Review the Service Agreement with the prospective provider to clarify provisions that are applicable to the provider, highlighting specific, applicable provisions for providers who employ persons providing direct services, those who will provide the services directly, and/or those who propose to provide services as an Independent Provider.
• Check the services to be provided and complete fee/unit information.  Note:  Fees may not exceed those identified in Rule 72.
• If the provider is an individual or an Independent Provider, assess their training and experience by obtaining and reviewing a resume. Complete an interview, if necessary, to obtain clarification on qualifications, deciding whether the individual or Independent Provider meets the general qualifications outlined on the Service Agreement form. Agency SE/CE providers will have credentials or certification from DDD or DBH; verify as outlined in #1, above.  See bullet below regarding background check process to be followed.
• If the Service Agreement is for Individual Supported or Customized Employment, review and provide copies and instruction on how to complete the required reporting forms.
• Office Director reviews, discusses, and completes required documentation to obtain background checks applicable to the individual and Independent providers, as follows:
  • When the Independent Provider box is marked ‘yes,’ ask the prospective provider for their Medicaid Provider Number and tell them Nebraska VR will conduct background checks in addition to those completed in the Medicaid enrollment process by Maximus.
  • When the prospective provider has: 1) checked ‘yes’ in response to the question about whether the individual named, business owner(s) or business principles directly provide services; and, 2) proposes to provide any of the services marked with an asterisk (*) on the Service Agreement form, Nebraska Department of Education (NDE) will complete background checks.  Follow the NDE Background checks process for providers, as outlined in the User guide found at this link:

https://insidende.education.ne.gov/offices/human-resources/policies-procedures#HRPoliciesProcedures (>Filling vacant positions policy >Contractor/VR Background Check Request Process)

• NOTE: Once the signatures are received on the background check forms in AdobeSign, the Office Director forwards the AdobeSign email to Terri Donahue in NDE HR.
• NOTE: Office Directors: It would be helpful to the prospective provider if you follow-up with them to ensure they are checking their inbox and junk/spam folders for the background check emails. If any of the information for the DHHS follow-up email is filled out incorrectly, a notary will be required to verify identity so this part of the check can be completed. There is an attachment located here that shows the first few screens of info that are required for the DHHS check. After these screens, there are also verification questions that must be answered (such as which of these vehicles is one you have owned previously, which of these street addresses have you lived at, etc.). All verification questions must be completed in one sitting, using a computer (not cell phone) and have a time limit.
• The Service Provider completes the section of the Service Agreement to verify lawful presence in the US and completes/signs the applicable section of the Agreement.
• The Office Director/VR Director signs the Service Agreement, obtains the prospective provider's signature, and explains the Agreement is not in force until background checks are received. EXCEPTION REQUEST:  An Office Director may request an exception to policy to execute the Service Agreement before background check results are obtained.  The rationale for the request will be made in writing to the Nebraska VR Director.  The decision to grant an exception will consider whether the client and provider will have unobserved one-to-one contact in the workplace or home and the need for services to begin immediately. Upon granting of an exception, the service provider will be entered into QE2.
• The Service Agreement is emailed to the State Office. NOTE: The effective date of the Service Agreement is the start date on the agreement OR the date it is received at the State Office, whichever is later. 

6.  The Office Director has the prospective provider complete the State of Nebraska Substitute Form W-9/ACH Enrollment Form. If applicable, complete the ACH portion of the form to arrange for direct deposit of payments and obtain one of the four documents listed in the lower right-hand corner of the W9/ACH Form.

7.  The Office Director scans the following documents to vr.providers@nebraska.gov

• Signed Service Agreement with attachments, if applicable 
• Signed W9/ACH form and documentation for direct deposit, if applicable

8. Office Director enters provider in QE2 Create Provider, if applicable.

9. NDE HR receives and sends background check reports to vr.providers@nebraska.gov  Nebraska VR evaluates the results.  If there are concerns with a background check, Nebraska VR Director will make the final decision about whether the Service Agreement will be executed.

10. When the prospective provider has passed background checks Nebraska VR State Office notifies the Office Director and approves the provider in QE2.

11. The Office Director and other local VR staff, as applicable, meet with the service provider to complete arrangements to implement the Service Agreement, including monitoring service outcomes and effectiveness. The Office Director must review the Service Agreement annually with the service provider following the process outlined in #13 below.

12. Special note regarding the termination of Independent Providers:  When an Independent Provider’s Medicaid enrollment is terminated, the VR Office Director is notified by email from the DDD Service Coordinator.  The email is scanned to the client’s VR electronic case record and a copy is forwarded to the VR Fiscal Director who ensures the Independent Provider is notified of the termination of the Service Agreement. (See Service Agreement for additional details to follow in terminating a Service Agreement.)

13. Process to complete and document annual review of Service Agreements:  The Service Agreement is reviewed annually. This review is intended to ensure continued understanding of and adherence to each requirement of the Agreement and so that any questions about the tenets of the Agreement may be discussed to ensure continued compliance. For providers with multiple Service Agreements, multiple area programs, and/or Agreements signed by different people for different programs, complete the review with each person who has signed the agreement, i.e., if an agency representative signs all Agreements, the review of all is completed with that person or their local designee.  If each area program’s Agreement is signed by a different person, the Agreement should be reviewed with the person who signed the Agreement. Office Director completes the review using the following process:

• At time of signing, discuss the expectation of annual review with the provider and identify a reminder method for review on an annual basis 
• Annually, meet with person who signed the Agreement or their designee (may be local director responsible for carrying out day-to-day operations, ensuring Service Agreement compliance) to review contract points.  Consider specifically highlighting clauses that prohibit subcontracting, background check and assurances, general qualifications/expectations, as well as other points that may require reminders for compliance  
• Obtain any updated credentials, licensure documentation, as applicable
• Document in QE2 in the Provider record with a “NEW COMMENT” the date of the review, name of person with whom review was completed, and any other pertinent notes. 

 

ABI/Autism SE Supplemental Questionnaire

Service Agreement

List of Background Checks