1. A VR Office 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 under a Service Agreement with VR. A Service Agreement with an Independent Provider is permitted only so long as the Independent Provider maintains his / her 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 – Hearing Impaired
• Benefits Assessment
• Benefits Planning
• Benefits – PASS Development
• Benefits Management
• Rehab Technology – Rehab Engineering
• Independent Living Training
• Individual Supported Employment (with type specified)
• Customized Employment (with type specified)

3. If the prospective provider will provide Individual Supported Employment Services, 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 BH authority
• An agency provider of I/DD Supported Employment or Customized Employment must be certified 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
• A prospective provider of ABI / Autism Supported Employment must submit responses to the questions on Attachment:  Questionnaire to support Service Agreement development for ABI/Autism
• 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 any applicable 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.  (Note that in the case of the Benefits services, this is done in conjunction with State Office Fiscal staff.) Documentation should be current and the expiration date of the license or certification noted for entry into QE2.    

5. Complete top section of the 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 completes the next section:  Effective Dates, determination of whether the prospective provider is an Independent Provider, and whether mileage will be paid.
• If the ‘yes’ box is checked for Independent Provider, obtain the person’s Medicaid Provider Number and write it in the space provided. Note: when an Independent Provider has a Medicaid Provider Number they have passed a background check conducted by Maximus for DHHS.  See below for additional required checks if the prospective Independent Provider has lived or worked outside of the state of Nebraska.
• 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. 

 

6. 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. At this point, information about whether the individual or Independent Provider has lived or worked outside of the State of Nebraska may also be obtained.  Make a decision about whether the individual or Independent Provider meets the general qualifications outlined on the Service Agreement form.  Agency providers will have credentials or certification from DDD or DBH; verify as outlined in #1, above.  See #6 below regarding background checks. 

7. If the Service Agreement is for Individual Supported Employment or Customized employment, review and provide copies and instruction on how to complete the applicable Milestone Definition and Payment Schedule (BH, ABI/Autism, I/DD Supported Employment or I/DD Customized Employment), and required reporting forms.

8. Office Director reviews, discusses, and completes required documentation to obtain background checks applicable to the provider:

• When the Independent Provider box is marked ‘yes,’ ask the prospective provider for their Medicaid Provider Number.  NE background checks have already been completed during the Medicaid enrollment process, but for internal processing purposes, the prospective provider completes page 1 of the Division of Children and Family Services Child Abuse/Neglect / Adult Protective Services Registry Form to be submitted with the completed Service Agreement
• 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, follow this process:

(A) Notify him/her that the background screen must be completed before a Service Agreement may be executed and that failure to authorize a background check will result in delay of Service Agreement processing.  In order to have adequate processing time, forward the required information at least two weeks in advance of the proposed agreement start date

(B) Have the prospective provider complete page 1 of the Division of Children and Family Services Child Abuse/Neglect / Adult Protective Services Registry Form.  Retain the form for submission with the signed Service Agreement to VR State Office  

(C) Have the prospective provider request Central Registry Checks online by utilizing the online DHHS portal at the dedicated link below.  The person will be able to view results of the Registry check following the submittal of the information and may print the findings.  The General Counsel’s Office will also track the progress of the request online, view the final status, and print the results for their use 

DEDICATED LINK:

               https://ecmp.nebraska.gov/DHHS-CR/CheckRequest/BeginOrgCheck/80209924

(4)  The prospective provider will need an email address to complete the form online through the DHHS portal. If they do not have one, the form can be filled out and mailed with the Service Agreement to:  vr.providers@nebraska.gov  

(5)  NDE personnel may not enter the information for the prospective provider. This is a violation of Nebraska Revised Statute 28-725.

NOTE:  When the Agreement is with a service provider employing individuals who will provide direct services, the authorized representative’s signature on the Agreement gives written assurance that the persons the service provider employs to provide the direct services have not been convicted of a felony or misdemeanor involving neglect or abuse of a child or vulnerable adult.

9. Using the State of Nebraska Substitute Form W-9 & ACH Enrollment Form, the Office Director has the prospective provider complete the W-9 information at the top, and, if applicable, the ACH portion of the form, to arrange for direct deposit of payments, then obtains 1 of the 4 documents from the list on the right-hand corner of the W9/ACH form.

10.  The service provider completes the section to verify lawful presence in the US and completes/signs the applicable section of the agreement.

11.  Office Director signs the Service Agreement, obtains the prospective provider’s signature, and explains that the Agreement is not in force until background checks are received. *

   * Exception Requests:  An Office Director may request an exception to policy in order to execute a Service Agreement before background check results are obtained.  The rationale for the request will be made in writing to the VR Director.  The decision to grant an exception will take into consideration whether there is potential that the client and provider will have unobserved one-to-one contact in the workplace or home as well as the need for services to begin immediately. Upon granting of an exception, the service provider will be entered into QE2.  

         12. Office Director scans the following documents to this dedicated VR State Office email address: vr.providers@nebraska.gov

• Signed Service Agreement with Milestone Payment Schedule(s) for applicable SE / CE program(s) 
• Page 1 of the Division of Children and Family Services Child Abuse/Neglect / Adult Protective Services Registry Form, if applicable
• Signed W9/ACH form and documentation for direct deposit, if applicable

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

14. Upon receipt of scanned documents, VR State Office staff forwards Page 1 of the Division of CFS A/N / APS Registry Form to NDE Legal to complete background checks.

15. NDE Legal staff complete the following background checks and communicate the results to VR State Office:  

• Department of Motor Vehicles (DMV)
• State Patrol 
• DHHS Registries
• Nebraska Sex Offender Registry
• Additional out-of-state checks determined necessary when the prospective provider has lived or worked outside of the State of Nebraska

   16. When the prospective provider does not pass the background screen.

       The VR State Office Staff: 

• Notifies the Office Director and VR Director
• Notes the failed background screen on the provider record in QE2, and, if services are being provided under an exception agreement, immediately inactivates the agreement in QE2.

       The Office Director:

• Notifies the prospective provider that the Service Agreement cannot be executed, and,
• If services are being provided under an exception request, the Office Director sends the provider a written notice terminating the agreement immediately in accordance with the terms of the Service Agreement regarding background screens.  Immediately is defined as:  the next action taken after learning that the provider did not pass the background checks

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

 18. 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 #19 below. 

19.  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 printed and placed in the client’s VR case record for the client and is forwarded to the VR Fiscal Director who ensures the Independent Provider is notified of the termination of the Service Agreement.

 20.   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 / signers 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 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 sub-contracting, 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 Provider record with a “NEW COMMENT” the date of the review, name of person with whom review was completed, and any other pertinent notes. 

 

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 – Hearing Impaired, Benefits Assessment, Benefits Planning, Benefits-PASS Development, Benefits Management, Rehab Technology – Rehab Engineering, Independent Living Training, Individual Supported Employment, and Customized Employment.  

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

ABI/Autism SE Supplemental Questionnaire

Service Agreement