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r-+ <br /> M 'J <br /> 7 <br /> 13. To submit billing for approved medical clinical serrr3.ci <br /> and DEC services on Form HNC©-01, EPSDT of :form number <br /> 372--109, Family` Planning Visit Record Form DHS 1458, <br /> Maternal Health Data Record 2771, Child Health Pzl=ary <br /> Care Patient Data Form. 2769, or H.S_T_S_ Terminal and <br /> mail, to Division of Health services, -Box 2091, Raleigh,, - <br /> North Carolina 27602_ T <br /> 14. The local,-providers Will comply with 42 CFR Part 455, <br /> utilization control, review, by participating in the <br /> assessment of Standards for Local Health Departments, <br /> and site reviews of Standards for Developmental Evalua- <br /> tion Centers. <br /> The Division of Health Services Agrees: — <br /> 1. To serve as intermediary between the 'North Carolina Medical <br /> Assistance Program and the Provider including assistance <br /> j with billing, payment, cost determination, cost settle- <br /> ment, and renegotiation of reimbursement rates. <br /> 2. To make vendor payments for service at the negotiated fee <br /> per visit rate in accordance with the applicable lawns or <br /> DHS policy and as promptly as is feasible after a proper <br /> claim is submitted and approved.. <br /> i <br /> 3. To withhold payments, if necessary, because of irregula-city <br /> from whatever cause until such irregularity or difference <br /> t <br /> i <br />