This document discusses common issues or "gotchas" health centers encounter when completing Form 5A for their scope of project. It provides guidance on how to correctly document different service delivery methods, including contracted services, telehealth, and transportation. The top five gotchas covered are 1099 staff and contracted organizations, contract language requirements, pharmaceutical services, telehealth, and transportation. Tips are provided to avoid gotchas, such as using the self-assessment worksheet, service descriptors, and column descriptors, as well as involving multiple staff and the project officer when completing Form 5A.

1. Top Form 5A Condition
“Gotchas” and How to Avoid Them
Michelle Layton BSN, MBA
Infidium Healthcare Solutions, LLC
michellel@infidiumhs.com

2. Disclaimers
 This presentation is not endorsed by Management
Strategists Consulting Group (MSCG).
 This presentation is not endorsed by Health Resources
Services Administration (HRSA) or the Bureau of
Primary Health Care (BPHC).
 Not employed by MSCG or BPHC.
 Independent Consultant who is contracted to conduct
Operational SiteVisits (OSV), provide Technical
Assistance and assist health centers prepare for their
OSV.
 This information should not be considered legal advice.
Confidentiality Notice: This document is confidential and contains proprietary information and intellectual
property of Infidium Healthcare Solutions. Neither this document nor any of the information contained herein
may be reproduced or disclosed under any circumstances without the express written permission of the
aforementioned party. 2

3. Agenda
 What We Already Know About Form 5A
 What has Changed during COVID-19
 Top Five “Gotchas”
 What Goes Where?
 Tips to Avoid a “Gotcha”
 Question and Answer Session

4. What We Already Know

5. What is Scope of Project?
A health center’s scope of project defines the activities
supported by the Health Center Program project
budget. Specifically, scope of project defines the
approved service sites, services, providers, service
area(s) and target population(s).
https://bphc.hrsa.gov/programrequirements/scope.html

6. What is Scope of Project?
A health center’s scope of project is reflected on
the following forms in the Service Area
Competition (SAC) Application
 Form 5A - Services
 Form 5B - Sites
 Form 5C - Other Activities

7. What is Scope of Project?
 Form 5A defines the service being provided, as
well as the method of service delivery.
 Form 5B identifies the sites where the services
on Form 5A are being provided.
 Form 5C identifies other activities the health
center may be conducting, such as hospital
admitting and health fairs.

8. Why is Scope of Project Important?
 Scope demonstrates the health center’s
commitment to HRSA.
 Scope is reflective of the operations of the
health center
 Scope must be accurate for purposes of:
◦ Medicare/Medicaid FQHC Reimbursement
◦ FTCA Coverage
◦ 340B Drug Pricing Program Benefits

9. What Has Changed
During COVID-19

10. Post-COVID-19
 Postponement of onsite Operational SiteVisits (OSVs).
 Sudden surge in the use of telehealth to deliver
services.
 Confusion regarding how to correctly document
telehealth services on Form 5A.
 The need to continue to maintain compliance with
Scope of Project throughout the Pandemic.
 The implementation of theVirtual OSV process.

11. Top Five Gotchas

12. Gotcha #1:
1099 Staff and Contracted
Organizations

13. Form 5A
What GoesWhere?
• Column I – Services are provided directly by W-2
employees of the health center or National Health
Service Corps.
• Column II – Services are provided through a formal
written contract/agreement which the health center
pays for. This includes 1099 staff who provide services
on-site.
• Column III – Services are provided through a formal
written referral arrangement which the health center
does NOT pay for.

14. Gotcha #2:
Contract Language

15. Contract Language for Column II Services
What Goes Where?
 How the service will be documented in the
patient’s medical record.
 How the health center will pay for the service.
 Appropriate credentialing and privileging of the
provider for the contracted service, per Chapter 5,
“Clinical Staffing” of the Compliance Manual.
 Sliding Fee Language

16. Contract Language for Column III Services
What Goes Where?
 The manner by which referrals will be made and
managed.
 The process for tracking and referring patients back
to the health center for appropriate follow-up care.
 Appropriate credentialing and privileging of the
provider for the referred service, per Chapter 5,
“Clinical Staffing” of the Compliance Manual.
 Sliding Fee Language

17. Gotcha #3:
Pharmaceutical Services

18. Pharmaceutical Services
What Goes Where?
 Guidance on placement of Pharmaceutical Services was
provided to Consultants in December of 2017.
 All 340B Contracted Pharmacy - Column II
 Other Examples:
◦ In-house Pharmacy staffed withW-2 Employees –
Column 1
◦ In-house Pharmacy staffed with 1099 staff – Column II
◦ Pharmacy samples provided by W-2 employees –
Column I
◦ Pharmacy samples provided by 1099 staff – Column II

19. Gotcha #4:
Telehealth

20. What is Telehealth?
Telehealth is a mechanism or means for delivering a
health service(s) to health center patients using
telecommunications technology or equipment
https://bphc.hrsa.gov/sites/default/files/bphc/programrequireme
nts/pdf/telehealth-pal.pdf

21. Telehealth
What GoesWhere?
 Telehealth is simply a mechanism for service delivery.
 Telehealth is not a separate entry on Form 5A.
 Services provided via telehealth should be documented
on Form 5A like all other services.
 Telehealth Examples:
◦ General Primary Medical Care Services delivered by a
W-2 employee should be reflected as a Column I
service.
◦ Psychiatry services provided by a contracted
organization the health center pays for should be
listed as a Column II service.

22. Gotcha #5:
Transportation

23. Transportation
What GoesWhere?
 Providing bus tokens to patients is considered a gray
area but is typically listed as a Column I service.
 Although the health center may have a line item in the
budget for tokens, there is typically no contract in place.
 Contracted transportation services should be reflected
in Column II. The contract must have ALL the required
language.
 Talk with your Project Officer regarding the placement
of bus tokens and/or if you are not able to secure a
contract with the required language.

24. Tips to Avoid a “Gotcha”

25. Clinical Reviewer Considerations
 Complete the Health Center Self-Assessment Worksheet on the
HRSA website.
 Utilize the Service Descriptors and Column Descriptors when
completing Form 5A.
 Involve multiple staff members when completing Form 5A.
 Review all Column II and Column III agreements for required
language.
 If you are unsure of which Column a service should be listed in,
always contact your Project Officer.
 Remember that Form 5A should be a working document and will
change as the health center adds or removes services.

26. Resources
 Compliatric
https://www.compliatric.com/
 Policy Information Notice (PIN) 2008-01
Scope of Project Policy Information Notice
 Program Assistance Letter (PAL) 2020-01
Telehealth Program Assistance Letter
 Health Center Self-AssessmentWorksheet
Self-AssessmentWorksheet

27. Resources
 Form 5A Service Descriptors
Form 5A Service Descriptors
 Form 5A Column Descriptors
Form 5A Column Descriptors

28. Questions & Answers

29. Michelle Layton BSN, MBA
Infidium Healthcare Solutions, LLC
michellel@infidiumhs.com