Common use of BENEFIT PROGRAM REQUIREMENTS Clause in Contracts

BENEFIT PROGRAM REQUIREMENTS. PPG agrees: 1. That all Member Physicians will comply with the terms and conditions of this Addendum, the terms of the applicable Benefit Programs, and of the Operations Manual. 2. To comply with FHS efforts to provide Case Management. PPG agrees to provide PPG’s written treatment plan within five (5) working days of receipt of request from FHS. A treatment plan includes a statement of diagnosis, current patient condition, current or proposed treatment, and anticipated outcomes. 3. That if PPG admits or arranges for an inpatient admission to a non-Participating Provider or facility for an elective procedure, PPG shall document that PPG has given such Member prior notice of the following: a) Provider or facility is non-participating; b) The non-Participating Provider or facility will not be restricted to seeking payment only from FHS; and c) The non-Participating provider or facility may xxxx the Member for amounts other than deductibles, Copayments, and medical services not covered under the Member’s Coverage Certificate. 4. That PPG may appeal a Utilization/Care Management decision as set forth in the Operations Manual. 5. FHS agrees that any determination under the Utilization/Care Management Program that a Member’s services rendered by PPG were not Medically Necessary shall not retroactively affect PPG’s right to payment hereunder if such services were authorized by FHS prior to admission and the information provided by PPG to FHS regarding the Member’s medical condition was substantially true and accurate.

BENEFIT PROGRAM REQUIREMENTS. PPG agrees: 1. That all Member Physicians will comply with the terms and conditions of this Addendum, the terms of the applicable Benefit Programs, and of the Operations Manual. 2. To comply with FHS efforts to provide Case Management. Management PPG agrees to provide PPG’s written treatment plan within five (5) working days of receipt of request from FHS. A treatment plan includes a statement of diagnosis, current patient condition, current or proposed treatment, and anticipated outcomes. 3. That if PPG admits or arranges for an inpatient admission to a non-Participating Provider or facility for an elective procedure, PPG shall document that PPG has given such Member prior notice of the following: a) Provider or facility is non-participating; b) The non-Participating Provider or facility will not be restricted to seeking payment only from FHS; and c) The non-Participating provider or facility may xxxx bill the Member for amounts other than deductibles, Copayments, and medical services not covered under the Member’s Coverage Certificate. 4. That PPG may appeal a Utilization/Care Management decision as set forth in the Operations Manual. 5. FHS agrees that any determination under the Utilization/Care Management Program that a Member’s services rendered by PPG were not Medically Necessary shall not retroactively affect PPG’s right to payment hereunder if such services were authorized by FHS prior to admission and the information provided by PPG to FHS regarding the Member’s medical condition was substantially true and accurate.

BENEFIT PROGRAM REQUIREMENTS. PPG agrees: 1. That all Member Physicians will comply with the terms and conditions of this Addendum, the terms of the applicable Benefit Programs, and of the Operations Manual. 2. To comply with FHS efforts to provide Case Management. PPG agrees to in provide PPG’s written treatment plan within five (5) working days of receipt of request from front FHS. A treatment plan includes a statement of diagnosis, current patient condition, current or proposed treatment, and anticipated outcomes. 3. That if PPG admits or arranges for an inpatient admission to a non-Participating Provider or facility for an elective procedure, PPG shall document that PPG has given such Member prior notice of the following: a) Provider or facility is non-participating;: b) The non-Participating Provider or facility will not be restricted to seeking payment only from FHS; : and c) The non-Participating provider or facility may xxxx bill the Member for amounts other than deductibles, Copayments, and medical services not covered under the Member’s Coverage Certificate. 4. That PPG may appeal a Utilization/Care Management decision as set forth in the Operations Manual. 5. FHS agrees that any determination under the Utilization/Care Management Program that a Member’s services rendered by PPG were not Medically Necessary shall not retroactively affect PPG’s right to payment hereunder if such services were authorized by FHS prior to admission and the information provided by PPG to FHS regarding the Member’s medical condition was substantially true and accurate.

BENEFIT PROGRAM REQUIREMENTS. PPG agrees: 1. That all Member Physicians will comply with the terms and conditions of this Addendum, the terms of the applicable Benefit Programs, and of the Operations Manual. 2. To comply with FHS efforts to provide Case Management. PPG agrees to provide PPG’s written treatment plan within five (5) working days of receipt of request from FHS. A treatment plan includes a statement of diagnosis, current patient condition, current or proposed treatment, and anticipated outcomes. 3. That if it PPG admits or arranges for an inpatient admission to in a non-Participating Provider or facility for an elective procedure, PPG shall document that PPG has given such Member prior notice of the following: a) Provider or facility is non-participating; b) The non-Participating Provider or facility will not be restricted to seeking payment only from FHS; and c) The non-Participating provider or facility may xxxx hill the Member for amounts other than deductibles, Copayments, and medical services not covered under the Member’s Coverage Certificate. 4. That PPG may appeal a Utilization/Care Management decision as set forth in the Operations Manual. 5. FHS agrees that any determination under the Utilization/Care Management Program that a Member’s services rendered by PPG were not Medically Necessary shall not retroactively affect PPG’s right to payment hereunder if such services were authorized authorised by FHS prior to admission and the information provided by PPG to FHS regarding the Member’s medical condition was substantially true and accurate.

BENEFIT PROGRAM REQUIREMENTS. PPG agrees: 1. That all Member Physicians will comply with the terms and conditions of this Addendum, the terms of the applicable Benefit Programs, and of the Operations Manual. 2. To comply with FHS HNI efforts to provide Case Management. PPG agrees to provide PPG’s written treatment plan within five (5) working days of receipt of request from FHSHNI. A treatment plan includes a statement of diagnosis, current patient condition, current or proposed treatment, and anticipated outcomes. 3. That if PPG admits or arranges for an inpatient admission to a non-Participating Provider or facility for an elective procedure, PPG shall document that PPG has given such Member prior notice of the following: a) Provider or facility is non-participating; b) The non-Participating Provider or facility will not be restricted to seeking payment only from FHSHNI; and c) The non-Participating provider Provider or facility may xxxx the Member for amounts other than deductibles, Copayments, and medical services not covered under the Member’s Coverage Certificate. 4. That PPG may appeal a Utilization/Care Management decision as set forth in the Operations Manual. 5. FHS HNI agrees that any determination under the Utilization/Care Management Program that a Member’s services rendered by PPG were not Medically Necessary shall not retroactively affect PPG’s right to payment hereunder if such services were authorized by FHS HNI prior to admission and the information provided by PPG to FHS regarding the Member’s medical condition was substantially true and accurate.provided