HomeMy WebLinkAbout2022-321-E-Health-UNC Healthcare System-BCCCP Mammogram ScreeningRevised 6/21
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[Departmental Use Only]
TITLE UNC BCCCP Program
FY 2022-2023
ORANGE COUNTY
UNC BCCCP PROGRAM CONTRACT
NORTH CAROLINA
THIS AGREEMENT, made and entered into this first day of July, 2022, (“Effective Date”) by and
between Orange County, North Carolina, a political subdivision of the State of North Carolina, (the
"County"), party of the first part; and UNC Health Care System (the "Provider"), party of the second part;
W I T N E S S E T H:
For the purpose and subject to the terms and conditions hereinafter set forth, the County hereby
contracts for the services of the Provider, and the Provider agrees to provide the following services to the
County in accordance with the terms of this Agreement, time being of the essence:
The services and/or materials (hereinafter referred to collectively as “Services”) to be furnished
under this Agreement are as follows: See Exhibit A "NC BREAST AND CERVICAL CANCER
PROGRAM" and Exhibit B "North Carolina Breast and Cervical Cancer Control Program 2022
Services Fee Schedule" and any amendments thereto, both of which are attached and hereby incorporated by
reference.
The term of this agreement rendered shall be from July 1, 2022 to June 30, 2023.
Provider represents and agrees that Provider is qualified to perform and fully capable of performing and
providing the services required or necessary under this Agreement in a fully competent, professional and
timely manner to the satisfaction of the County. Provider shall be responsible for all errors or omissions, in
the performance of the Agreement. Provider shall correct any and all errors, omissions, discrepancies,
ambiguities, mistakes or conflicts at no additional cost to the County. Provider agrees that Provider shall not
sub-contract any of the services to be provided in this Agreement, nor shall Provider assign any right or
responsibility granted or required by this Agreement, without the prior written approval of the County.
SPECIFIC TERMS
1. Payment: The County agrees to pay at the rates specified for Services satisfactorily
performed in accord with this Agreement. The amount to be paid by the County shall not exceed Four
Thousand Five Hundred Dollars ($4,500) and at the rate provided in Exhibit B and any amendments thereto.
The County shall monitor Services requested to limit Services to those that can be covered by the maximum
amount stated in this Agreement. Payment shall be made within thirty (30) days of an invoice properly
submitted to County. Should Provider fail to perform its duties under the terms of this Agreement, County
may, without fault or penalty, withhold any payment associated with the work to be performed until such
time as said work is completed.
2. Non–waiver: Failure by County at any time to require the performance by Provider of any
of the provisions hereof shall in no way waive or affect the County's right hereunder to enforce the same, nor
shall any waiver by the County of any breach be held to be a waiver of any succeeding breach or a waiver of
this Non-Waiver Clause.
3. Independent Contractor: The Provider shall operate as an independent contractor and the
County shall not be responsible for any of the Provider’s acts or omissions. The Provider shall not be treated
as an employee with respect to the Services performed hereunder for federal or state tax, unemployment or
workers' compensation purposes. The Provider understands that neither federal, nor state, nor payroll tax of
any kind shall be withheld or paid by the County on behalf of the Provider or the employees of the Provider.
DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18
Revised 6/21
2
4. Insurance : Provider, an agency of the State of North Carolina, is responsible for its and its
employees' negligence as provided under North Carolina law. Provider shall maintain professional liability
self-insurance coverage sufficient to adequately insure itself during the performance of these services.
5. Indemnity: The Provider agrees to defend, indemnify, and hold harmless Orange County
from all losses, liabilities, claims, demands, suits, costs, damages or expenses (including reasonable
attorney's fees), to the extent provided by the North Carolina Tort Claims Act, arising from bodily injury,
including death, to any person or persons or damage to or destruction of any property caused in whole or in
part by any negligent or intentional act or omission on the part of the Provider, its agents, or assigns directly
or indirectly related to the Services to be performed pursuant to this Agreement on the part of the Provider.
6. Termination: This Agreement may be terminated at any time by mutual written agreement of
the parties or by the County upon written notice to the Provider. County may suspend this Agreement upon
reasonable notice to the Provider.
7. Entire Agreement and Signatures: The parties have read this Agreement and agree to be
bound by all of its terms, and further agree that it constitutes the complete and exclusive statement of the
Agreement between the parties unless and until modified in writing and signed by the parties. This
Agreement together with any amendments or modifications may be executed electronically. All electronic
signatures affixed hereto evidence the intent of the Parties to comply with Article 11A and Article 40 of
North Carolina General Statute Chapter 66.
8. Priority: In determining the basic services to be provided, should any documents be
referenced in or attached to this Agreement, the terms of this Agreement shall have priority in any conflict
between the terms of referenced documents and the terms of this Agreement.
9. Governing Law: Both parties agree that this Agreement shall be governed by the laws of the
State of North Carolina. Provider shall at all times remain in compliance with all applicable local, state, and
federal laws, rules, and regulations including but not limited to all state and federal anti-discrimination laws,
policies, rules, and regulations and the Orange County Non-Discrimination Policy. Any violation of this
requirement is a breach of this Agreement and County may immediately terminate this Agreement without
further obligation on the part of the County. This paragraph is not intended to limit and does not limit the
definition of breach to discrimination. By executing this Agreement Provider affirms that Provider is and
shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By
executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the
services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58.
By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the
services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S.
147-86.81.
10. Dispute Resolution: Any and all suits or actions to enforce, interpret, or seek damages with
respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in
the General Court of Justice of North Carolina sitting in Orange County, North Carolina. It is agreed by the
parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding
arbitration may not be initiated by either Party, however, the Parties may agree to nonbinding mediation of
any dispute prior to the bringing of such suit or action.
11. Non Appropriation: Provider acknowledges that County is a governmental entity, and the
validity of this Agreement is based upon the availability of public funding under the authority of its statutory
mandate. In the event that public funds are unavailable and not appropriated for the performance of County’s
obligations under this Agreement, then this Agreement shall automatically expire without penalty to County
immediately upon written notice to Provider of the unavailability and non-appropriation of public funds.
DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18
Revised 6/21
3
IN WITNESS WHEREOF, County and the Provider have signed this Agreement, effective as of
the day first written above.
ORANGE COUNTY PROVIDER
By: _________________________ By: _________________________
County Manager Title: ________________________
200 S. Cameron St. UNC Health Care System
P.O. Box 8181 5221 Paramount Parkway, Suite 420
Hillsborough, NC 27278 Morrisville, NC 27560-5491
DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18
System Vice President, Managed Care
This Letter of Agreement between our respective organizations outlines the reimbursement terms
and conditions whereby UNC Faculty Physicians (UNC FP) will provide services related to breast
and cervical cancer screening for patients as referred by the Orange County Health Department
(OCHD). This letter will cover services provided on dates of service between July 1, 2022 and June
30, 2023. UNC FP shall comply with State regulations and local medical standards. For these
services, UNC FP agrees to accept as payment in full reimbursement rates as outlined on the “North
Carolina Breast and Cervical Cancer Control Program 2022 Services Fee Schedule” (Fee Schedule)
attached hereto as Exhibit B. Hospital services, if any, are excluded from this agreement, as are any
services provided by UNC FP that are not listed on the Fee Schedule. UNC FP further agrees to
seek payment only from the OCHD and will not seek payment from individual patients for services
covered under this agreement.
OCHD and UNC FP agree that UNC FP is an independent contractor and shall not represent i tself
as an agent or employee of OCHD for any purpose in the performance of UNC FP’s duties under
this contract.
To the extent permitted by the NC Tort Claims Act, the UNC FP shall indemnify and hold harmless
the OCHD, its officials, agents, and employees from and against all claims, damages, losses, and
expenses, (including but not limited to fees and charges of attorneys and other professionals and
costs related to court action or arbitration) arising out of or resulting from the performance of this
agreement or the actions of the UNC FP or its officials, employees, or contractors under this
agreement. This indemnification shall survive the termination of this agreement.
UNC FP represents that it is in compliance with all applicable Federal, State, and local laws,
regulations or orders, as amended or supplemented. The implementation of this contract will be
carried out in strict compliance with all Federal, State, or local laws. If applicable, UNC FP shall
comply with HIPAA Privacy rules effective April 2003 and HIPAA Security regulations and
guidelines effective February 2005.
Either party may terminate this agreement by giving thirty (30) days written notice to the other
party.
OCHD will notify Elizabeth Bullard of patients being referred to UNC as part of this program.
Identification will occur preferably by email, or otherwise phone, to:
UNC Hospitals – Gynecology Oncology Clinic
Elizabeth Bullard
P (984) 215-5888
F (984) 974-9039
Elizabeth.Bullard2@unchealth.unc.edu
Exhibit A
NC Breast and Cervical Cancer Program
DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18
UNC FP will send invoices to:
Orange County Health Department, BCCCP Program
ATTN: Accounts Payable
Post Office Box 8181
Hillsborough, NC 27278
OCHD agrees to submit payment for these services within thirty (30) business days of the date the
invoice is received. Payments should be submitted to:
UNC Faculty Physicians- Integrated Billing
PO Box 168
Chapel Hill, NC 27514
DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18
2022 Office Fee
Code Fee Allowed
Clinical breast examination N/A Yes
77063 51.44$ No
77063TC 22.48$
77063-26 28.96$
77067 124.70$ No
77067TC 88.60$
77067-26 36.11$
Radiological examination, surgical specimen 76098 39.52$ No
76098TC 24.37$
76098-26 15.15$
Diagnostic mammography, unilateral, includes CAD 77065 122.58$ No
77065TC 84.10$
77065-26 38.48$
Diagnostic mammography, bilateral, includes CAD 77066 154.81$ No
77066TC 107.22$
77066-26 47.58$
G0279 51.44$ No
G0279TC 22.48$
G0279-26 28.96$
Ultrasound, complete examination of breast including axilla,76641 101.19$ No
unilateral (4)76641TC 66.44$
76641-26 34.75$
Ultrasound, limited examination of breast including axilla, 76642 83.08$ No
unilateral (4)76642TC 50.70$
76642-26 32.37$
Surgical evaluation/Consultation N/A (10)Yes
Fine needle aspiration biopsy without imaging guidance, first lesion 10021 99.10$ Yes
Each additional lesion 10004 50.07$ Yes
Fine needle aspiration biopsy including ultrasound guidance, first lesion 10005 134.99$ Yes
Each additional lesion 10006 59.28$ Yes
Punch biopsy of skin (including simple closure when performed), single lesion 11104 123.44$ Yes
Each additional lesion 11105 57.78$ Yes
11106 152.72$ Yes
Each additional lesion 11107 69.81$ Yes
Puncture aspiration of cyst of breast 19000 100.63$ Yes
Puncture aspiration of cyst of breast, each additional cyst, used with 19000 19001 26.23$ Yes
Breast biopsy, with placement of localization device and imaging of 19081 499.59$ Yes
biopsy specimen, percutaneous; stereotactic guidance; first lesion (5)
Each additional lesion (5) 19082 389.49$ Yes
Breast biopsy, with placement of localization device and imaging of 19083 505.26$ Yes
biopsy specimen, percutaneous; ultrasound guidance; first lesion (5)
Each additional lesion (5)19084 385.18$ Yes
Breast biopsy, percutaneous, needle core, not using imaging guidance 19100 151.33$ Yes
Breast biopsy, open, incisional 19101 326.29$ Yes
Diagnostic digital breast tomosynthesis, unilateral or bilateral (3)
North Carolina Breast and Cervical Cancer Control Program
Breast Cancer Screening and Diagnostic Procedures
2022 Services Fee Schedule (1)
For the Period 01/01/2022 through 12/31/2022
Incisional biopsy of skin (e.g., wedge; including simple closure when
performed), single lesion
Revised: 03/08/2022
Screening mammography, bilateral, includes CAD
Screening
Screening digital breast tomosynthesis, bilateral (2)
Follow-Up
Exhibit BDocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18
2022 Office Fee
Code Fee Allowed
Excision of cyst, fibroadenoma or other benign or malignant tumor, 19120 508.42$ Yes
aberrant breast tissue, duct lesion, nipple or areolar lesion; open;
one or more lesions
Excision of breast lesion identified by preoperative placement of 19125 560.85$ Yes
radiological marker; open; single lesion
Each additional lesion separately identified by a preoperative 19126 157.73$ Yes
radiological marker
Placement of breast localization device, percutaneous; mammographic 19281 234.57$ Yes
guidance; first lesion (6)
Each additional lesion (6)19282 166.26$ Yes
Placement of breast localization device, percutaneous; stereotactic 19283 255.36$ Yes
guidance; first lesion (6)
Each additional lesion (6)19284 189.95$ Yes
Placement of breast localization device, percutaneous; ultrasound 19285 371.95$ Yes
guidance; first lesion (6)
Each additional lesion (6)19286 305.90$ Yes
Ultrasonic guidance for needle placement, imaging 76942 56.72$ No
supervision and interpretation 76942-TC 26.30$
76942-26 30.42$
Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic 88172 52.71$ No
study to determine adequacy of specimen(s), first evaluation episode 88172TC 18.27$
88172-26 34.44$
Cytopathology, evaluation of fine need aspirate; immediate cytohistologic 88177 27.98$ No
study to determine adequacy of specimen(s), each separate additional 88177TC 6.74$
evaluation episode 88177-26 21.24$
Cytopathology, evaluation of fine needle aspirate; interpretation and report 88173 151.21$ No
88173TC 82.70$
88173-26 68.51$
Surgical pathology, gross and microscopic examination 88305 68.59$ No
88305TC 32.08$
88305-26 36.51$
Surgical pathology, gross and microscopic examination; requiring microscopic 88307 273.42$ No
evaluation of surgical margins 88307TC 193.18$
88307-26 80.24$
Morphometric analysis, tumor immunohistochemistry, per specimen; manual 88360 115.73$
88360TC 75.11$
88360-26 40.62$
Morphometric analysis, tumor immunohistochemistry, per specimen; 88361 115.66$
using computer-assisted technology 88361TC 72.86$
88361-26 42.79$
00400 21.07$
Moderate anesthesia, 10-22 minutes for individuals 5 years or older (8)99156 75.05$
Each additional 15 minutes (8)99157 61.15$
North Carolina Breast and Cervical Cancer Control Program
2022 Services Fee Schedule (1)
Breast Cancer Screening and Diagnostic Procedures
Anesthesia for procedures on the integumentary system, anterior trunk, not
otherwise specified (7)
DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18
2022 Office Fee
Code Fee Allowed
Pelvic examination - Bimanual N/A Yes
Cytopathology, cervical or vaginal, any reporting system, requiring 88141 21.48$
Cytopathology (liquid-based Pap test) cervical or vaginal, collected 88142 20.26$
in preservative fluid, automated thin layer preparation; manual
screening under physician supervision
Cytopathology, cervical or vaginal, collected in preservative fluid,88143 23.04$
automated thin layer preparation; manual screening and rescreening
under physician supervision
Cytopathology (conventional Pap test), slides cervical or vaginal 88164 15.92$
reported in Bethesda System, manual screening under physician
supervision
Cytopathology (conventional Pap test), slides cervical or vaginal 88165 42.22$
reported in Bethesda System, manual screening and rescreening under
physician supervision
Cytopathology, cervical or vaginal, collected in preservative fluid,88174 25.37$
automated thin layer preparation; screening by automated system,
under physician supervision
Cytopathology, cervical or vaginal, collected in preservative fluid,88175 26.61$
automated thin layer preparation; screening by automated system and
manual rescreening, under physician supervision
Human Papillomavirus, high-risk types (9)87624 35.09$ No
Human Papillomavirus, types 16 and 18 only (9)87625 40.55$ No
Colposcopy of the cervix 57452 124.55$ Yes
Colposcopy of the cervix, with biopsy and endocervical curettage 57454 167.16$ Yes
Colposcopy of the cervix, with biopsy 57455 159.19$ Yes
Colposcopy of the cervix, with endocervical curettage 57456 149.32$ Yes
Surgical pathology, gross and microscopic examination 88305 68.59$ No
88305TC 32.08$ No
88305-26 36.51$ No
Surgical pathology, gross and microscopic examination; requiring 88307 273.42$ No
microscopic evaluation of surgical margins 88307TC 193.18$ No
88307-26 80.24$ No
2022 Services Fee Schedule (1)
Cervical Cancer Screening and Diagnostic Procedures
Follow-Up
Screening
interpretation by physician
North Carolina Breast and Cervical Cancer Control Program
DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18
CPT 2022
Code Fee
New patient; medically appropriate history/exam, straightforward decision- 99202 70.70$
making; 15-29 minutes
New patient; medically appropriate history/exam; low level decision-making; 99203 109.00$
30-44 minutes
Established patient; evaluation and management, may not require 99211 22.25$
presence of physician; presenting problems are minimal
Established patient; medically appropriate history/exam, straightforward 99212 54.79$
decision-making; 10-19 minutes
Established patient; medically appropriate history/exam; low level decision-99213 88.29$
making; 20-29 minutes
Established patient; medically appropriate history/exam; moderate level 99214 124.76$
decision-making; 30-39 minutes
CPT 2022
Code Fee
Telephone evaluation and management (E/M) by physician or other qualified 99441 54.22$
healthcare professional; 5-10 minutes medical discussion
Telephone evaluation and management (E/M) by physician or other qualified 99442 88.00$
healthcare professional; 11-20 minutes medical discussion
Telephone evaluation and management (E/M) by physician or other qualified 99443 124.76$
healthcare professional; 21-30 minutes medical discussion
determine their usage for your facility. The following are the codes and definitions that apply:
G = Global - the all-inclusive fee for performing and interpreting the service.
TC = Technical Component - the fee for performing the service.
26 = Professional Component - the fee for interpreting the service.
Physician Visits
Global and Split Fees
Both global and split fees apply to the breast and cervical procedures listed on this fee schedule. The method and direction of payment will
Telehealth Visits
Telephone Visits (11)
Office Visits (10)
North Carolina Breast and Cervical Cancer Control Program
2022 Services Fee Schedule (1)
DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18
(1)NC BCCCP covers only the physician's fee. Any facility charges associated with these CPT codes are not covered.
(2)
(3)
(4)Bilateral ultrasound may be reimbursed at one and one-half times the unilateral rate (not double unilateral rate).
(5)
(6)
(7)
(8)Example: If procedure is 50 minutes, code 99156 + (99157 x 2). No separate charge allowed if procedure <10 minutes.
(9)
(10)
(11)
HPV DNA testing is not reimbursable if used as an adjunctive screening test to a Pap for women under 30 years of age.
Not to exceed 3 base units plus time units (length of time spent providing anesthesia service in 15-minute increments) times
conversion rate ($21.07) or $325, whichever is lower. Medicare's methodology for the payment of anesthesia services is outlined
in chapter 12 of the Medicare Claims Processing Manual at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
The carrier-specific Medicare anesthesia conversion rates are available at:
https://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center
NOTES:
Codes 19281-19286 are for image guidance placement of localization device without image-guided biopsy. These codes should
not be used in conjunction with 19081-19084.
List separately in addition to 77065 or 77066.
Codes 19081-19084 are to be used for breast biopsies that include image guidance, placement of localization device, and
imaging of specimen. They should not be used in conjunction with 19281-19286.
List separately in addition to code for primary procedure 77067.
The Centers for Medicare & Medicaid Services (CMS) currently allow telehealth visits to be billed using standard office visit
CPT codes during the public health emergency. These visits can be performed using routine technology platforms (e.g., phones,
facetime, free Zoom, etc.) and relaxes the use of only HIPAA-compliant platforms. Future allowance for the use of telehealth
will be based upon guidance we receive post-pandemic. By law, NC BCCCP can only cover Medicare-approved and allowable
procedures.
All consultations should be billed through the standard "new patient" office visit CPT codes: 99202-99205. Consultations billed
as 99204 or 99205 must meet the criteria for these codes, and must be pre-authorized. Codes 99204 and 99205 are typically not
appropriate for NC BCCCP screening visits, but may be used when provider spends extra time to do a detailed risk assessment.
BCCCP may pay for up to two surgical consultations.
DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18
Procedures CPT Code Fee
Automated Lipid Panel *80061 13.39$
Lipid Panel (CLIA waived)1 80061QW 13.39$
Cholesterol, Total Serum 82465 4.35$
Cholesterol, Total Serum (CLIA waived) 82465QW 4.35$
Lipoprotein (HDL)83718 8.19$
Lipoprotein (HDL) (CLIA waived) 83718QW 8.19$
Glucose, blood, quantitative 82947 3.93$
Glucose, blood, quantitative (CLIA waived) 82947QW 3.93$
Glucose, blood, reagent strip 82948 5.04$
Glucose, tolerance test, three specimens 82951 12.87$
Glucose, tolerance test, three specimens (CLIA waived) 82951QW 12.87$
Hemoglobin A1C 83036 9.71$
Hemoglobin A1C (CLIA waived) 83036QW 9.71$
Basic Metabolic Profile **80048 8.46$
Basic Metabolic Profile (CLIA waived)** 80048QW 8.46$
Other
Routine venipuncture 36415 3.00$
Health Coaching (HC) - Initial HC session is incorporated into screening visit;
2 additional HC sessions are advised and will be reimbursed as below:
Individual HC, Face-to-face, 15 minutes 98960 15.00$
Individual HC, Phone, 15 minutes 98967 15.00$
Office Visits
New Patient, medically appropriate history/exam; 15-29 minutes 99202 70.70$
New Patient; medically appropriate history/exam; 30-44 minutes 99203 109.00$
New Patient, medically appropriate history/exam; 45-59 minutes 99204 162.93$
New Patient; medically appropriate history/exam; 60-74 minutes 99205 215.62$
Established Patient; evaluation and management; minimal problems 99211 22.25$
Established Patient; medically appropriate history/exam; 10-19 minutes 99212 54.79$
Established Patient; medically appropriate history/exam; 20-29 minutes 99213 88.29$
Established Patient; medically appropriate history/exam; 30-39 minutes 99214 124.76$
Note: Office Visits listed above may be used to reimburse for consultations associated with WISEWOMAN
referrals, when applicable.
*Lipid Panel tests are: Total Serum Cholesterol, Lipoprotein (HDL and LDL) and Triglycerides.
**Basic
Metabolic Profile
1 The Clinical Laboratory Improvement Amendments of 1988 (CLIA) law specifies that laboratory
requirements be based on the complexity of the test performed and established provisions for categorizing a
test as waived. Tests may be waived from regulatory oversight if they meet certain requirements
established by the statute. CLIA waived tests employ methodologies that are so simple and accurate as to
render the likelihood of erroneous results negligible; pose no reasonable risk of harm to the patient if the
test is performed incorrectly; and/or are cleared by the Food and Drug Administration for home use.
North Carolina Breast and Cervical Cancer Control Program
Maximum Allowable Fees - WISEWOMAN Program
For the Period: 01/01/2022 - 12/31/2022
Collection Container: 1 mL Serum / One SST Remarks: Includes NA, K, CL, CO2,
GLUC, BUN, CREA, CA
Revised: 01/03/2022
DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18
Revised 06/21
ORANGE COUNTY—DEPARTMENT USE ONLY
______________________________________________________________________________
Party/Vendor Name: UNC Healthcare System Party/Vendor Contact Person: Kathryn Grant Contact Phone: 984-
974-1274 Party/Vendor Address: 5221 Paramount Parkway, Suite 420 City Morrisville State: NC Zip: 27560
Department: Health Amount: $5,000 Purpose: BCCCP Mammogram Screening Budget Code(s): 10414020-
631010-71401 Vendor # 30892 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract
Type: (Check one) New Renewal Amendment Effective Date 7-1-22 Approved by Board Yes No
Agenda Date: --- For Section XIV. c. contracts only, Approved by Board in Current FY Budget Yes No
This agreement is approved as to technical form and content and I as Department Director affirmatively state work
on this project has not been initiated prior to execution of the agreement:
Department Director’s Signature ________________________________________ Date: ________
Agreements for emergency services or repair are not subject to the above affirmation. If services related to this
agreement have already begun or been completed please briefly describe the nature of the emergency condition that
was addressed:
Information Technologies
(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is
approved as to information technology content and specifications:
Office of the Chief Information Officer___________________________________ Date: ________
Risk Management
This agreement is approved for sufficiency of insurance standards, specifications, and requirements:
Office of the Risk Management Officer___________________________________ Date: _________
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control
Act:
Office of the Chief Financial Officer ____________________________________ Date: _________
Legal Services
This agreement is approved as to legal form and sufficiency:
Office of the County Attorney __________________________________________Date: ________
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board __________________________________________Date:_________
DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18
7/28/2022
7/28/2022
7/28/2022
7/28/2022
CERTIFICATE OF COVERAGE
FOR
THE STATE OF NORTH CAROLINA
(For information purposes Only)
Certificate Holder: Public Officers & Employee Liability Insurance Commission
of North Carolina and the General Statutes of North Carolina, Chapter
143, Articles 31 to 31D, Sections §143-291 to § 143-300.
http://www.ncleg.net/EnactedLegislation/Statutes/HTML/ByArticle/Chapter_143/Article_31.html
http://www.ncleg.net/EnactedLegislation/Statutes/HTML/ByArticle/Chapter_143/Article_31A.html
Period: February 01, 2022 until February 01, 2023
Coverage: A)
B)
Tort Claims against Departments, Agencies, and Employees
Excess Liability for State Employees
Ambridge Partners, LLC – Policy # PK1035822;
Kinsale Insurance Company – Policy #0100154762-1
Limits A)
B)
$1,000,000 for Tort claims against the State
$2,000,000 per employee/$10,000,000 aggregate for claims
against state employees
Description: The State of North Carolina and its employees, officers, agents, as
covered by the Defense of State Employees as per NCGS § 143 300.2.
Administrator: Department Insurance - Risk Management Division
Public Officers & Employees Liability Insurance Commission
1202 Mail Service Center, Raleigh, NC 27699-1202
Note: This Certificate is for informational purposes only and does not alter any
provision of the Tort Claims or Defense of State Employees General
Statutes of the State.
Verified By:
Bryan Heckle, CIC, CPCU, CRM
Deputy Commissioner of Risk Management
POELIC Certificate
DocuSign Envelope ID: F603CD10-1FD6-4458-9C7C-EC1EB8CD2D18