Monterey farmworkers design ways to combat Covid-19 with Natividad Medical Center
Article By: Aisling Carroll
Clinicians from Natividad Medical Center meet with farmworkers in Monterey County about COVID-19. Photo credit: Natividad Medical Center.
Meeting in Fields and Parking Lots
Alongside some of the highest-producing fields in the world, Dr. Erika Romero, a medical resident at Natividad Medical Center used to a gleaming hospital floor underfoot, stood on an outdoor gravel parking lot in Monterey County’s Salinas Valley.
She spoke with a group of farmworkers who had stopped cutting cauliflower and bagging lettuce to talk about Covid-19. This was Natividad’s first coronavirus outreach “charlas” (chat).
Yes, the coronavirus was real. No, a sore throat might not just be a sign of a cold; it could be Covid-19. Yes, it is safe to go to the hospital.
But none of these workers knew anyone who was sick. Some of them were skeptical. Rumors abounded. It was early April, before the CDC recommended wearing masks, before doctors wore spacesuits on the news, before the County reported more than a handful of Covid-19 infections.
Dr. Romero and her colleagues, however, knew Covid-19 was trying to take hold.
They also knew that these farmworkers, who were unable to shelter-in-place because of their essential work, would suffer disproportionately. The numbers and suffering could be an unthinkable catastrophe. Some 55,000 lived or were temporarily working in Monterey County for the harvest season. These agricultural workers make up many of the patients at Natividad, which is the only public health care system in the region and the area’s only level two trauma center.
Because the average California farmworker makes $20,500 per year, they are subject to a multitude of virus-friendly situations that make them acutely vulnerable to Covid-19. For example, many can’t socially distance because they can’t afford a car that would allow them to drive to work solo. So instead, they often carpool or rely on employer vans, and sit inches from each other.
When they arrive at the fields and packing houses, it’s difficult for them to physically separate from their two-dozen strong crew members and efficiently work the land.
And at the end of their day, most farmworkers return to a crowded home. Due to the high cost of housing in California and their low pay, many share rooms with other families and multiple generations of their own.
Farmworkers are frequently in situations where they must move, stand or sit next to someone, which significantly increases their coronavirus risk.
They also often lack access to health care and may have underlying health conditions (e.g., respiratory issues) due to the nature of their work, which can make them more susceptible to the disease. And many cannot get coverage through Medi-Cal because of their immigration status. Others don’t seek medical attention because of the fear of deportation, the cost of care or lost wages if they miss work.
These circumstances put their health and lives at greater risk, and could compromise the nation’s food supply and any progress the community makes against the pandemic at risk.
Because the average California farmworker makes $20,500 per year, they are subject to a multitude of virus-friendly situations that make them acutely vulnerable to Covid-19.
The First “Charlas” (Chats)
Working furiously to cut the coronavirus off at the pass in February, Natividad started blanketing the farmworker community with Covid-19 information (public service announcements, newsletters, hotlines and Facebook posts) in Spanish, and sometimes in indigenous languages. Although more than 90 percent of California farmworkers are Latinx, thousands of farmworkers in Monterey County speak an indigenous language from Mexico, such as Triqui or Mixteco, and little to no Spanish.
The hospital also secured 40,000 high-quality masks for farmworkers from an apron maker, thanks to one of its resident’s ingenuity. And Natividad Foundation later secured funding for an additional 5,000 reusable masks for farmworkers.
Still, Natividad was well aware of the many barriers farmworkers faced to obtaining information and resources.
“Not everyone is going to have a smartphone they can afford right now. Not everyone is going to have Wi-Fi,” said Hillary Fish, Natividad’s director of marketing and community relations. She also couldn’t bank on them hearing a radio ad.
So Natividad’s medical residents and nurses, along with those of other area hospitals, went directly to speak with farmworkers in the fields and packing houses.
“I didn’t want to sit there and give a list of data,” said Dr. Romero. “I wanted to have a conversation.”
She guided several of Natividad’s outreach efforts (charlas), which ran from April through June and reached thousands of farmworkers.
During the talks, Dr. Romero was transparent about what the medical community knew at that moment in time and what it did not about Covid-19, which helped build trust. With many doubting what they could not see in the pandemic’s early days, she shared firsthand accounts of how the disease was not limited to the old and compromised.
“I’m seeing very young men who are in the ICU,” she told farmworkers during the charlas. These harrowing stories landed. Farmworkers grew concerned about the physical and financial impact Covid-19 might have on their families. They also recognized that Dr. Romero, a daughter of Salvadoran immigrants, was highly credible.
“I can relate to a lot of their experiences and understand their plights,” she said.
Then she flipped the script and turned the charlas over to the farmworkers: What were their biggest obstacles to staying safe? What were their greatest concerns? What solutions would work best in their environment?
The farmworkers designed and developed new ways of protecting themselves. For example, they created smaller cohorts that would carpool, work and eat together. That way, if one person contracted Covid-19, the virus might be contained to fewer people. Their strategy might also prevent the whole facility from shutting down and laying off workers, which was a looming worry.
“I didn’t want to sit there and give a list of data. I wanted to have a conversation.”
– Dr. Romero
Medics as Mediators
But before the farmworkers started brainstorming these strategies, they had to first feel safe enough to openly share ideas and concerns (e.g., a lack of PPE) without any fear of retribution from the foremen (“mayordormas”) who also participated in the charlas.
The workers and mayordormas “don’t always have the best of relationships,” said Dr. Romero. Mistrust can exist on both sides.
However, each group trusted Natividad’s clinicians. They had a reputation – decades in the making – of effectively caring for the community with no other agenda than promoting health.
As such, Dr. Romero and her colleagues were in the unique position of helping the two groups agree on coronavirus-related steps to take with “the ultimate goal of protecting everyone: the mayordormas, the workers, the infrastructure,” she said.
These mediations enabled the farmworkers and mayordormas to generate and agree upon, and implement specific solutions, including social distancing in employer vans and staggering breaks.
Dr. Romero and colleagues also collaborated on personalized plans to stop the spread.
“What can I do to not give this to my daughter with special needs?” one farmworker asked Dr. Romero as a charlas wrapped up.
The worker told Dr. Romero that she was scared. She had to work and wanted to help her team in the fields, but she didn’t want her daughter in harm’s way.
“So much of this is not about them but about their families,” said Dr. Romero.
The farmworker lived in a one-room home with another family, had diabetes and did not have health care. As she described her circumstances, she and Dr. Romero created a plan of what the worker would do as soon as she returned home, such as leaving her shoes in a designated area outside, as well as who she might call to access a doctor.
Taking Covid-19 precautions was only one part of what was discussed during the charlas. The other was what farmworkers would do if they had symptoms, had been exposed or tested positive, and how they could protect themselves physically, financially and emotionally in these situations.
Providing handouts in Spanish, Natividad residents and nurses discussed free testing and medical care, free housing for quarantining and state disability insurance, regardless of immigration status. Their objective was to discourage workers from showing up to work sick and spreading the virus.
“So much of this is not about them but about their families.”
– Dr. Romero
An Unusual Partnership
What may have mattered most about the charlas was the timing.
“We went into action early on,” said Dr. Romero. “And because of that, I think we saved so many lives.”
The key reason why Natividad Medical Center’s residents and nurses, as well as clinicians from other hospitals, were able to hold charlas-after-charlas in rapid-fire succession during the early days of the pandemic was because of an unusual partnership brokered by the hospital.
In March, a group of farmworker advocates, academics, county officials and hospitals – including Natividad – formed to protect farmworkers from Covid-19.
Called the Monterey County Coalition of Agriculture (MC-COA), the group wanted to help deploy clinicians from local hospitals to dozens of farms and packing houses to provide outreach education.
The roadblock was that no one around the virtual table had the resources or time to do the heavy lifting of organizing the logistics for each facility visit. It would take weeks.
Natividad knew one organization that might solve this problem: The Growers-Shipper Association (GSA). The hitch was that GSA represented the farmers and facility operators who many coalition members often disagreed with.
“They don’t always see eye-to-eye,” said Natividad’s Hillary Fish.
But keeping the big picture of putting critical information and masks into farmworkers’ hands ASAP was front of Fish’s mind. “Bringing the groups together was challenging at first, but we all had a common goal of protecting high-risk members of our community,” she said. “Fortunately, everyone wanted to do the right thing.”
And the right thing was everyone agreeing that GSA would get the word out to its 300 farm and facility members and others that medics wanted to conduct in-person education to farmworkers about Covid-19.
By taking the reins (and a risk) to involve other groups like GSA that could help, Natividad was able to greatly accelerate the speed at which life-saving information was shared, prevention measures implemented and behaviors changed.
“We went into action early on. And because of that, I think we saved so many lives.”
– Dr. Romero
Clinicians and staff from Natividad Medical Center meet with farmworkers to discuss strategies to mitigate the spread of COVID-19. Photo Credit: Natividad Medical Center.
A One-Two Punch
Even with these efforts, however, the Covid-19 surges still came. Starting in the summer and rising at alarming levels through the fall and winter, they have disproportionately affected farmworkers. According to a study from the California Institute for Rural Studies, Monterey County farmworkers were three times more likely to contract COVID-19 than those working in non-agricultural industries during the summer of 2020.
Unsurprisingly, Natividad’s work has not let up. Clinicians have continued to push hard, using what they’ve learned from farmworkers at the charlas to better meet worker needs.
Currently, the hospital’s doctors, nurses and communications team are working on a community-driven vaccine education campaign with farmworker organizations like GSA. MC-COA recently joined forces with a new organization in Monterey County called the COVID-19 Collaborative. Fish and several doctors from Natividad are active leaders of the group, which has further improved the hospital’s pandemic response.
The vaccine effort could not be more critical. Farmworkers who contract Covid-19 are more likely to become critically ill or die because of their often side-by-side working and living conditions, a lack of access to health care and a higher prevalence of chronic diseases.
But only half of Monterey County’s farmworkers reported they were “extremely likely” to get vaccinated, according to a December 2020 study led by researchers at the UC Berkeley School of Public Health. Natividad is leaning on the trust it has built up through its in-the-fields education campaign and continuing its listen-first approach to change minds.
“It has to be collaborative or it won’t work,” said Dr. Romero.
GPP PY9 Health Equity Reporting Manual User Agreement AMA PQA CMS v20231211
End User Agreement
Please review this agreement and click “Accept” at the end of this agreement if you agree to the terms of this agreement. If you do not agree, please click “Cancel”; in this case, you will not be able to access the Reporting Manual.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)
End User Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 American Medical Association (AMA). All Rights Reserved. CPT is a trademark of the AMA.
You, your employees and agents are authorized to use CPT only as contained in the QIP PY7 Reporting Manual solely for your own personal use and only for participating in state governmental healthcare related programs supported by and/or administered by California Health Care Safety Net Institute (SNI). You acknowledge that the “AMA” holds all copyright, trademark and other rights in CPT.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave, Suite 39300, Chicago, IL 60611-5885. Applications are available at the AMA Web site (http://www.ama-assn.org/go/cpt.).
U.S. GOVERNMENT RIGHTS
This product includes CPT which is commercial technical data, which was developed exclusively at private expense by the AMA, 330 Wabash Avenue, Chicago, IL 60611. The AMA does not agree to license CPT to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The AMA reserves all rights to approve any license with any Federal agency.
DISCLAIMER OF WARRANTIES AND LIABILITIES
CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with SNI, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.
This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this agreement.
CMS MEDICAID ADULT AND CHILD CORE SET
License Agreements
Please review the licensing information below and indicate your agreement and acceptance.
LICENSE FOR USE OF PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (CPT)
End User Point and Click Agreement:
CPT codes, descriptions and other data only are copyright 2021 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials of Centers for Medicare and Medicaid Services (CMS) internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid or other programs administered by CMS. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL 60654. Applications are available at the AMA website, http://www.ama-assn.org/go/cpt.
Applicable FARS\DFARS Restrictions Apply to Government Use. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the AMA, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL, 60611- 5885. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Defense Department procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non- Department of Defense Federal procurements.
AMA DISCLAIMER OF WARRANTIES AND LIABILITIES
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.
CMS DISCLAIMER
The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.
LICENSE FOR NATIONAL UNIFORM BILLING COMMITTEE (NUBC)
These materials contain the NUBC Official UB-04 Specifications Manual and data codes (UB-04 Data), which are copyrighted 2022 by the American Hospital Association (AHA), Chicago, IL. Reproduced with permission. No portion of the AHA copyrighted materials may be copied without express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816.
Making copies or utilizing the content of the UB-04 Manual, including codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of the UB-04 Manual or any portion thereof, including the codes and/or descriptions is only authorized with an express license from the AHA.
The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in the agreement. By clicking below on the button labeled “Accept” you hereby acknowledge that you have read, understood, and agreed to all terms and conditions set forth in this agreement.
If you do not agree with all terms and conditions set forth herein, click below on the button labeled “Do Not Accept” and exit from this computer screen.
If you are acting on behalf on an organization, you represent that you are authorized to act on behalf of such an organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. As used herein, “you” and “your” refer to you and any organization on behalf of which you are acting.
1. Subject to the terms and conditions contained in this agreement, you, your employees, and agents are authorized to use UB-04 Data only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of UB-04 Data is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the AHA holds all copyright, trademark, and other rights in UB-04 Data. You shall not remove, alter, or obscure any AHA copyright notices or other proprietary rights notices included in the materials.
2. Any use not authorized herein is prohibited, including, by way of illustration and not by way of limitation, making copies of UB-04 Data for resale and/or license, transferring copies of UB-04 Data to any party not bound by this agreement, creating any modified or derivative work of UB-04 Data, or making any commercial use of UB-04 Data. License to use UB-04 Data for any use not authorized herein must be obtained through the AHA, 155 N. Wacker Drive, Suite 400, Chicago, IL, 60606. Applications are available at the NUBC website, http://www.nubc.org/.
3. The UB-04 Data included in this product is commercial technical data and/or computer databases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the AHA, 155 N. Wacker Drive, Suite 400, Chicago, IL, 60606. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.
AHA DISCLAIMER
The AHA hasn’t reviewed and isn’t responsible for the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessary represent the views of the AHA. CMS and its products and services aren’t endorsed by the AHA or any of its affiliates.
AHA DISCLAIMER OF WARRANTIES AND LIABILITIES
UB-04 Data is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The sole responsibility for the software, including any UB-04 Data and other content contained therein, is with the Medicare/Medicaid Contractor or the CMS; and no endorsement by the AHA is intended or implied. The AHA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice to you if you violate the terms of this agreement. The AHA is a third-party beneficiary to this agreement.
CMS DISCLAIMER
The scope of this license is determined by the AHA, the copyright holder. Any questions pertaining to the license or use of the UB-04 Data should be addressed to the AHA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USE OF THE UB-04 DATA. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMMISSIONS OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “I agree”.
QIP PY7 Reporting Manual User Agreement AMA PQA CMS v20231211
End User Agreement
Please review this agreement and click “Accept” at the end of this agreement if you agree to the terms of this agreement. If you do not agree, please click “Cancel”; in this case, you will not be able to access the Reporting Manual.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)
End User Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 American Medical Association (AMA). All Rights Reserved. CPT is a trademark of the AMA.
You, your employees and agents are authorized to use CPT only as contained in the QIP PY7 Reporting Manual solely for your own personal use and only for participating in state governmental healthcare related programs supported by and/or administered by California Health Care Safety Net Institute (SNI). You acknowledge that the “AMA” holds all copyright, trademark and other rights in CPT.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave, Suite 39300, Chicago, IL 60611-5885. Applications are available at the AMA Web site (http://www.ama-assn.org/go/cpt.).
U.S. GOVERNMENT RIGHTS
This product includes CPT which is commercial technical data, which was developed exclusively at private expense by the AMA, 330 Wabash Avenue, Chicago, IL 60611. The AMA does not agree to license CPT to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The AMA reserves all rights to approve any license with any Federal agency.
DISCLAIMER OF WARRANTIES AND LIABILITIES
CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with SNI, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.
This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this agreement.
PHARMACY QUALITY ALLIANCE COPYRIGHT STATEMENT
By agreeing to this policy, user accepts the following limitations of the QIP’s use of the Pharmacy Quality Alliance (PQA) Opioid measures and code sets: To accurately calculate the measure rates, the PQA value sets are required. User acknowledges that the PQA measures and value sets will only be used for the sole purpose of evaluating and improving opioid use for populations served by Public Health Care Systems (PHS) and District and Municipal Hospitals (DMPH) and will not be used for other purposes. Except for the purpose indicated above, the PQA measures and value sets will not be used for any other commercial product, service or value-added benefit. User also acknowledges that the information and PQA value sets will not be forwarded or provided to anyone outside of SNI, the California Department of Health Care Services (DHCS), the PHS or the DMPH.
CMS MEDICAID ADULT AND CHILD CORE SET
License Agreements
Please review the licensing information below and indicate your agreement and acceptance.
LICENSE FOR USE OF PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (CPT)
End User Point and Click Agreement:
CPT codes, descriptions and other data only are copyright 2021 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials of Centers for Medicare and Medicaid Services (CMS) internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid or other programs administered by CMS. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL 60654. Applications are available at the AMA website, http://www.ama-assn.org/go/cpt.
Applicable FARS\DFARS Restrictions Apply to Government Use. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the AMA, AMA Plaza, 330 Wabash Ave., Suite 39300, Chicago, IL, 60611- 5885. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Defense Department procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non- Department of Defense Federal procurements.
AMA DISCLAIMER OF WARRANTIES AND LIABILITIES
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.
CMS DISCLAIMER
The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.
LICENSE FOR NATIONAL UNIFORM BILLING COMMITTEE (NUBC)
These materials contain the NUBC Official UB-04 Specifications Manual and data codes (UB-04 Data), which are copyrighted 2022 by the American Hospital Association (AHA), Chicago, IL. Reproduced with permission. No portion of the AHA copyrighted materials may be copied without express written consent of the AHA. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312-893-6816.
Making copies or utilizing the content of the UB-04 Manual, including codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of the UB-04 Manual or any portion thereof, including the codes and/or descriptions is only authorized with an express license from the AHA.
The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in the agreement. By clicking below on the button labeled “Accept” you hereby acknowledge that you have read, understood, and agreed to all terms and conditions set forth in this agreement.
If you do not agree with all terms and conditions set forth herein, click below on the button labeled “Do Not Accept” and exit from this computer screen.
If you are acting on behalf on an organization, you represent that you are authorized to act on behalf of such an organization and that your acceptance of the terms of this agreement creates a legally enforceable obligation of the organization. As used herein, “you” and “your” refer to you and any organization on behalf of which you are acting.
1. Subject to the terms and conditions contained in this agreement, you, your employees, and agents are authorized to use UB-04 Data only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of UB-04 Data is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the AHA holds all copyright, trademark, and other rights in UB-04 Data. You shall not remove, alter, or obscure any AHA copyright notices or other proprietary rights notices included in the materials.
2. Any use not authorized herein is prohibited, including, by way of illustration and not by way of limitation, making copies of UB-04 Data for resale and/or license, transferring copies of UB-04 Data to any party not bound by this agreement, creating any modified or derivative work of UB-04 Data, or making any commercial use of UB-04 Data. License to use UB-04 Data for any use not authorized herein must be obtained through the AHA, 155 N. Wacker Drive, Suite 400, Chicago, IL, 60606. Applications are available at the NUBC website, http://www.nubc.org/.
3. The UB-04 Data included in this product is commercial technical data and/or computer databases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the AHA, 155 N. Wacker Drive, Suite 400, Chicago, IL, 60606. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (December 2007) and FAR 52.227-19 (December 2007), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.
AHA DISCLAIMER
The AHA hasn’t reviewed and isn’t responsible for the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessary represent the views of the AHA. CMS and its products and services aren’t endorsed by the AHA or any of its affiliates.
AHA DISCLAIMER OF WARRANTIES AND LIABILITIES
UB-04 Data is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. The sole responsibility for the software, including any UB-04 Data and other content contained therein, is with the Medicare/Medicaid Contractor or the CMS; and no endorsement by the AHA is intended or implied. The AHA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice to you if you violate the terms of this agreement. The AHA is a third-party beneficiary to this agreement.
CMS DISCLAIMER
The scope of this license is determined by the AHA, the copyright holder. Any questions pertaining to the license or use of the UB-04 Data should be addressed to the AHA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USE OF THE UB-04 DATA. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMMISSIONS OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “I agree”.
