Client Services Agreement Development Checklist

Agreement #:
Provider Name:
Agreement Start Date: / Agreement End Date:
Checklist Completed by:
Agreement Sections / Affirmative (“X”) / If not, briefly explain why.
Table of Contents
Page numbers are correct
Basic Acronyms Table
Only contains terms that are commonly known to the general public
Definitions
Contains all terms whose meaning is not commonly known to the general public
Only citations are utilized to define terms that are already defined by law
Government links are included within definitions for terms that could benefit from clarification beyond the written definition
Introduction
The overall purpose of the Agreement is briefly explained (in 2-5 sentences)
The overall role of the Provider is explained (in 1-3 sentences)
Deliverables: Facility Standards, Facility Operational Requirements, and Facility/Program Licensing
All licenses/certificates required to perform the service are listed, and the Code of Maine Rules associated with the licenses/certificates are properly cited.
All licenses/certificates required of the Provider’s facility are listed, and the Code of Maine Rules associated with the licenses/certificates are properly cited.
Hours of operation of the Provider’s facility are listed.
Capacity of the Provider’s facility is listed, if applicable (e.g. # of treatment beds).
Deliverables: Provider Staffing: Position Types, Qualification, and Hiring/Retention Standards
All types of staff the Provider is required to hire and maintain are listed.
The qualifications (e.g. licensing/certification, training, experience) for all types of staff the Provider is required to hire and maintain are listed, including proper citations to the related Code of Maine Rules licenses/certificates.
Deliverables: Client Services Eligibility: Clinical/Income/Demographic Requirements to Receive Client Services and Provider Process for Eligibility Determination and Provider Methods for Provider Intake/Outreach
The expectations for how the Provider is to come into contact with clients are explained (e.g. client outreach, walk-ins, referrals from a particular entity).
Income eligibility requirements and the process to enforce them are explained, including any client co-payment or sliding-fee-scale payment systems.
Clinical eligibility requirements and the process to enforce them are explained.
Client Coverage Screening and Billing Methods: MaineCare and Private Health Insurance
Full section is included if any of the services provided under the Agreement could be covered under MaineCare if a recipient of services were a MaineCare member.
Only the following sentence is included if the services provided under the Agreement could be not covered under MaineCare if a recipient of services were a MaineCare member: “Provide assistance, to each individual who is found not to have Mainecare and is receiving services under this Agreement, in applying for MaineCare benefits within fourteen (14) days of the date such services are initiated”.
Client Services to be Provided to Qualified Clients
This section is divided into separate subsections to highlight the major/significant portions of the program/service to be provided.
If it is important that certain Provider staff members perform certain services, it is explained which type of staff member is to perform which duties.
When, where, and how the service is to be provided is explained.
Administrative Services Related to the Provision of Client Services: Recordkeeping, Data Collection/Management, and Supportive Documentation
All record keeping requirements are listed.
All data collection management requirements are listed.
All documentation that supports the provision of Client Services is listed.
Performance Measures
Performance Measure Column: the performance measure listed is quantifiable/measurable, and is not subjective in any way.
Assessment Cycle Column: the timeframe/frequency in which the Performance Measure from the “Performance Measure” column will actually be measured is listed.
Supportive Documentation Column: the document that will be used to validate the performance measure data submitted to the Department by the Provider via the Performance Measure Report, as the report only contains summary data.
Reports: Required Reports
Name of Report or On-site Visit Column: the name of the report due or on-site visit to be conducted by the Department is listed
Description or Appendix Column: the exact data to be contained in the report or the information to be reviewed during the on-site visit is listed, or an Appendix to be completed as the report or during the on-site visit is listed.
Reports: Reporting Schedule
Name of Report or On-site Visit Column: the same name of report due or on-site visit is listed as within the Name of Report or On-site Visit Column of the Required Reports table.
Reporting Period Captured in Report Column: the reporting period to be covered by the report/on-site visit for is listed.
Due Dates and/or Frequency: the due dates or frequency which the report/on-site visit is listed.