CENTERS PLAN FOR HEALTHY LIVING, LLC

SINGLE CASE AGREEMENT

This Single Case Agreement (“SCA”) effective March 24th,2020 is entered into by and among Centers
Plan for Healthy Living, LLC (“Centers Plan”) and Golden Dreams Day Care Center DBA Center of Life
(“Provider Name”), collectively referred to as the Parties.
RECITALS
Centers Plan is a health maintenance organization certified under Article 44 of the New York State Public
Health Law.
Centers Plan provides benefits for specified health care services furnished to persons enrolled under the
various benefits plans that it issues.
Provider is a healthcare provider duly licensed and or registered as applicable, to provide covered services
to persons enrolled in specified Health Benefit Programs.
DEFINITIONS
For purposes of this SCA, the following definitions will apply:
Covered Persons means those persons enrolled in a Health Benefit Program.
Covered Services means those medically necessary healthcare services for which Centers Plan provides
benefits to, or on behalf of, Covered Persons enrolled in a Health Benefit Program, pursuant to the terms
of that Health Benefit Program.
Health Benefit Program means the program(s) underwritten or administered by Centers Plan setting
forth covered benefits provided to a Covered Person pursuant to a subscriber contract between Centers
Plan and the Covered Person.
SCOPE OF AGREEMENT
Provider understands this is a limited agreement and does not entail participating privileges.
Provider agrees to provide copies of information within timeframes of written or verbal request from
Centers Plan.
Provider understands and agrees claims will be reviewed and paid in accordance with New York State
and Federal standard billing and payment rules. If claims are sent for processing before SCA is counter
executed, claims will be denied.
Provider agrees and understands that Centers Plan may inspect financial records concerning claims paid
on behalf of Covered Persons, records of staff who delivered or supervised the delivery of paid services to
Covered Persons, Covered Persons clinical records, and any other clinical or financial items related to the
claims paid on behalf of Covered Persons deemed necessary to assure compliance with applicable New
York State and or Federal laws, rules and regulations.
Provider shall be responsible for completion and retention of all necessary and customary documentation
required for the services provided under this Agreement and as required by law.
PROVISION OF COVERED SERVICES
By signing this Agreement, the Parties establish a limited agreement which enables Provider to provide
Covered Services to the individual (s) identified immediately below (“Member”).
Provider represents it has the appropriate approvals, including, but not limited to, applicable licenses,
certifications, registrations, and permits to provide Covered Services in accordance with New York state
and federal laws. Provider agrees to provide Covered Services to the Member within the scope of
Provider’s business, practice, and license. For the purpose of this Agreement, Covered Services and
person(s) are specifically set forth below.

Type Service Code Rate Dates:

Home Delivered Meals S9977 $25.00 Refer to current authorization
*Provider acknowledges and agrees that above compensation and dates are tied only to the authorizations
issued for members.

IN WITNESS WHEREOF, the parties have caused their duly authorized representatives to execute this
Letter of Agreement.

PROVIDER CENTERS PLAN FOR HEALTHY LIVING, LLC

By: _________________________________ By: _________________________________

Print Name: __________________________ Print Name: __________________________

Title: ________________________________ Title: ________________________________

Date: _______________________________ Date: ________________________________