Common use of Qualification Standards Clause in Contracts

Qualification Standards. In order to participate with BCBSM under this Agreement, Provider must have and maintain all of the following Qualification Standards at each Approved Site:  At a minimum, a multidisciplinary staff consisting of a board-certified or board-eligible psychiatrist, a fully licensed psychologist, and a clinical licensed master’s social worker (CLMSW) with a master’s degree in social work;  A community governing or advisory board;  A comprehensive range of mental health services offered to the community including individual and group psychotherapy, family counseling, and psychological testing. Additional services required by patients and the community may also be included. Emergency services are available on a 24 hour basis through program staff or referral to other appropriate community agencies;  Proof of current licensure, registration, or certification at all times of Professional Providers on staff;  Accreditation by at least one national accreditation organization approved by BCBSM, such as, but not limited to the following:  The Joint Commission (TJC),  Council on Accreditation of Services for Families and Children (COA),  Commission on Accreditation of Rehabilitation Facilities (CARF), or  American Osteopathic Association (AOA);  Significant involvement by a psychiatrist on staff to assure that the psychiatrist assumes overall responsibility for coordinating the care of all patients. Significant involvement by a psychiatrist in an Outpatient Psychiatric Care facility includes, but is not limited to: approval of the initial evaluation, certification of the diagnosis, certification of the treatment plan, evaluation of client progress, intervention for medical reviews, intervention for level of care changes, review at termination of treatment, and approval for psychological testing prior to administration;  Michigan licensure for psychiatric partial hospitalization for Outpatient Psychiatric Care facilities providing psychiatric day treatment,  Absence of inappropriate utilization or practices as identified through proven subscriber complaints, audits, and peer review, and,  Absence of fraud and illegal activities. Addendum C REIMBURSEMENT METHODOLOGY For each Covered Service performed, BCBSM will pay Provider the lesser of billed charges or the maximum payment level set forth in BCBSM's published Outpatient Psychiatric Care Rate Schedule (Rate Schedule). Most maximum payment levels are based on the Resource Based Relative Value Scale (RBRVS) developed by the Centers for Medicare and Medicaid Services (CMS), which is a schedule of relative procedure values that reflect the resource cost required to perform each service. The resource costs of the RBRVS system include physician time, training, skill, risk, procedure complexity, practice overhead and professional liability insurance costs. Values are assigned to each service in relation to the comparative value of all other services. The relative values are then multiplied by a BCBSM-specific conversion factor to determine overall payment levels. For procedure codes that have no CMS derived RBRVS value, BCBSM’s maximum payment level may be based on BCBSM’s medical consultants’ determination. Other factors that may be used in setting maximum payment levels include, but are not limited to, comparison to similar services, corporate medical policy decisions, analysis of historical charge data and geographic anomalies. BCBSM may adjust maximum payment levels based on factors such as site of care or BCBSM payment policy. Additionally, the maximum payment levels indicated on the Rate Schedule for each type of Professional Provider may vary, commensurate with the rendering provider’s level of licensure. BCBSM will periodically review Outpatient Psychiatric Care facility reimbursement to determine if modifications are necessary. BCBSM does not warrant or guarantee that the review process will result in increased reimbursement. Addendum D SERVICES FOR WHICH PROVIDER MAY XXXX MEMBER Provider may xxxx Member for:

Qualification Standards. In order to participate with BCBSM under this Agreement, Provider must be located in Michigan and must have and maintain all of the following Qualification Standards at each Approved Siteprimary and branch site:  At • Provider has a minimumcurrent participation agreement with BCBSM as a Traditional Outpatient Physical Therapy facility; • Provider must provide physical therapy services, and may also provide occupational therapy and/or speech and language pathology services; • Provider has current Medicare certification as a rehabilitation agency for outpatient physical therapy services, or current Medicare participation as a comprehensive outpatient rehabilitation facility (CORF), and can demonstrate it provides services that are restorative and rehabilitative in nature; • Provider, or at least one licensed physical therapist on staff, must have membership in a local or national physical therapy professional organization; • Provider has a Michigan licensed physical therapist on site whenever physical therapy is provided, a multidisciplinary staff consisting of a board-certified or board-eligible psychiatrist, a fully Michigan licensed psychologistoccupational therapist on site whenever occupational therapy is provided, and a clinical Michigan licensed masterspeech therapist on site whenever speech-language pathology therapy is performed, except as may be otherwise permitted in BCBSM’s social worker (CLMSW) with published policies. If the state of Michigan has not released license applications or has not issued licenses for Speech-Language Pathologists, then a master’s degree in social workCertificate of Clinical Competence from the American Speech and Hearing Association is an acceptable alternative until the state issues licenses;  A community governing or advisory board;  A comprehensive range • Provider has written policies and procedures that meet generally acceptable standards for outpatient physical therapy to assure the quality of mental health services offered to the community including individual and group psychotherapy, family counselingpatient care, and psychological testingProvider demonstrates compliance with such policies and procedures; • Provider can demonstrate that it conducts program evaluation and utilization review to assess the appropriateness, adequacy and effectiveness of the program’s administrative and clinical components; • Provider’s outpatient physical therapy program has been in operation for six months prior to application to BCBSM for participation as an Outpatient Physical Therapy Facility and has sufficient patient volume to enable BCBSM to determine Provider’s compliance with BCBSM’s Qualification Standards; • Provider meets BCBSM’s Evidence of Necessity (EON) requirements, as applicable; • Provider complies with Certificate of Need (CON) requirements of the Michigan Public Health Code, as applicable; • Provider has a governing board that is legally responsible for the total operation of the facility, and for ensuring that quality care is provided in a safe environment; • Provider has, at the time of initial application to and affiliation in the TRUST OPT Facility Network, the capacity to provide Covered Services to new patients that are Members and to continue to provide Covered Services to existing patients that are Members. Additional services required by patients and the community may also be included. Emergency services are available on a 24 hour basis through program staff or referral to other appropriate community agencies;  Proof of current licensure• Provider can satisfactorily demonstrate sound financial stability, registration, or certification at all times of Professional Providers on staff;  Accreditation by at least one national accreditation organization approved as determined by BCBSM, such asduring the last five years. • Provider can satisfactorily demonstrate, but not limited as determined by BCBSM, an ability to the following:  The Joint Commission (TJC)cooperate with BCBSM,  Council on Accreditation of Services for Families its customer groups and Children (COA),  Commission on Accreditation of Rehabilitation Facilities (CARF), or  American Osteopathic Association (AOA);  Significant involvement by a psychiatrist on staff to assure that the psychiatrist assumes overall responsibility for coordinating the care of all patients. Significant involvement by a psychiatrist in an Outpatient Psychiatric Care facility includes, but is not limited to: approval of the initial evaluation, certification of the diagnosis, certification of the treatment plan, evaluation of client progress, intervention for medical reviews, intervention for level of care changes, review at termination of treatmentMembers, and approval for psychological testing prior the general provider community. • Provider can satisfactorily demonstrate, as determined by BCBSM, that it is free of conflicts of interest relative to administration;  Michigan licensure for psychiatric partial hospitalization for Outpatient Psychiatric Care facilities providing psychiatric day treatmentBCBSM,  Absence of inappropriate its customer groups, and Members. • Provider has satisfactory, as determined by BCBSM, utilization history or practices practice patterns, as identified through proven BCBSM’s use management programs, valid subscriber complaints, audits, or audits and peer review. • During the prior five year period, andProvider,  Absence its officers, directors, owners and all those with significant authority and responsibility cannot have any of fraud the following if related to the provision of or payment for health care, or if BCBSM determines that they affect Provider’s ability to provide Covered Services to Members; exclusions from state or federal programs, convictions, guilty pleas, nolo contendere pleas, remands to diversion programs, or civil judgments or settlements of civil actions. • If Provider, its officers, directors, owners and illegal activitiesall those with significant authority and responsibility have a history of Medicare certification revocations, suspensions, surrenders, disciplinary limitation, probations, state or federal program exclusions, or have been subject to a Corporate Integrity Agreement or found to have been non-compliant with anti- kickback laws and regulations, then Provider will be considered for network affiliation, or continued affiliation, at BCBSM’s sole discretion. Addendum C REIMBURSEMENT METHODOLOGY For each Covered Service performedServices performed that are within Provider’s scope of practice, BCBSM will pay Provider the lesser of the billed charges charge or the published maximum payment level per service, less any Deductible or Copayment for which the Member is responsible. The published maximum payment is set forth in BCBSM's published ’s Maximum Payment Schedule or Freestanding Outpatient Psychiatric Care Rate Physical Therapy Facility Fee Schedule (Rate “Payment Schedule”). Most maximum payment levels are based on BCBSM will make the Resource Based Relative Value Scale (RBRVS) developed by the Centers for Medicare and Medicaid Services (CMS), which is a schedule of relative procedure values that reflect the resource cost required Payment Schedule available to perform each serviceProviders via web-DENIS. The resource costs of the RBRVS system include physician time, training, skill, risk, procedure complexity, practice overhead and professional liability insurance costs. Values are assigned to each service in relation Nationally imposed changes to the comparative value nomenclature and national coding system (HCPCS) for procedural codes, and corrections of all typographical errors may result in immediate modifications to the Payment Schedule without prior notice. No other services. The relative values are then multiplied by a BCBSM-specific conversion factor modification to determine overall payment levels. For procedure codes that the Payment Schedule will become effective until after 90 days have no CMS derived RBRVS value, elapsed from the date of BCBSM’s maximum payment level notice to Providers. Notice may be based on BCBSM’s medical consultants’ determinationprovided either in written or electronic form. Other factors that may be used Written form shall include publication in setting maximum payment levels the Record or other appropriate BCBSM provider publication. Electronic notice shall include, but are not be limited to, comparison to similar services, corporate medical policy decisions, analysis of historical charge data and geographic anomalies. BCBSM may adjust maximum payment levels based publication on factors such as site of care or BCBSM payment policy. Additionally, the maximum payment levels indicated on the Rate Schedule for each type of Professional Provider may vary, commensurate with the rendering provider’s level of licensureweb-DENIS. BCBSM will review reimbursement levels periodically review Outpatient Psychiatric Care facility reimbursement to determine and may adjust them if BCBSM determines modifications are necessary. BCBSM does not warrant or guarantee that the review process will result in increased reimbursement. Addendum D SERVICES FOR WHICH PROVIDER MAY XXXX BILL MEMBER Provider may xxxx bill Member for:

Qualification Standards. In order to participate with BCBSM under this Agreement, Provider must be located in Michigan and must have and maintain all of the following Qualification Standards at each Approved Siteprimary and branch site:  At • Provider must provide physical therapy services, and may also provide occupational therapy and/or speech and language pathology services; • Provider has current Medicare certification as a minimumrehabilitation agency for outpatient physical therapy services, or current Medicare participation as a comprehensive outpatient rehabilitation facility (CORF), and can demonstrate it provides services that are restorative and rehabilitative in nature; • Provider, or at least one licensed physical therapist on staff, must have membership in a local or national physical therapy professional organization; • Provider has a Michigan licensed physical therapist on site whenever physical therapy is provided, a multidisciplinary staff consisting of a board-certified or board-eligible psychiatrist, a fully Michigan licensed psychologistoccupational therapist on site whenever occupational therapy is provided, and a clinical Michigan licensed masterspeech therapist on site whenever speech-language pathology therapy is performed, except as may be otherwise permitted in BCBSM’s social worker (CLMSW) with published policies. If the state of Michigan has not released license applications or has not issued licenses for Speech-Language Pathologists, then a master’s degree in social workCertificate of Clinical Competence from the American Speech and Hearing Association is an acceptable alternative until the state issues licenses;  A community governing or advisory board;  A comprehensive range • Provider has written policies and procedures that meet generally acceptable standards for outpatient physical therapy to assure the quality of mental health services offered to the community including individual and group psychotherapy, family counselingpatient care, and psychological testing. Additional services required by patients Provider demonstrates compliance with such policies and procedures; • Provider can demonstrate that it conducts program evaluation and utilization review to assess the community may also be included. Emergency services are available on a 24 hour basis through appropriateness, adequacy and effectiveness of the program’s administrative and clinical components; • Provider’s outpatient physical therapy program staff or referral has been in operation for six months prior to other appropriate community agencies;  Proof of current licensure, registration, or certification at all times of Professional Providers on staff;  Accreditation by at least one national accreditation organization approved by BCBSM, such as, but not limited application to the following:  The Joint Commission (TJC),  Council on Accreditation of Services BCBSM for Families and Children (COA),  Commission on Accreditation of Rehabilitation Facilities (CARF), or  American Osteopathic Association (AOA);  Significant involvement by a psychiatrist on staff to assure that the psychiatrist assumes overall responsibility for coordinating the care of all patients. Significant involvement by a psychiatrist in participation as an Outpatient Psychiatric Care facility includesPhysical Therapy Facility and has sufficient patient volume to enable BCBSM to determine Provider’s compliance with BCBSM’s Qualification Standards; • Provider meets BCBSM’s Evidence of Necessity (EON) requirements, but is not limited to: approval as applicable; • Provider complies with Certificate of Need (CON) requirements of the initial evaluationMichigan Public Health Code, certification as applicable; • Provider has a governing board that is legally responsible for the total operation of the diagnosis, certification of the treatment plan, evaluation of client progress, intervention for medical reviews, intervention for level of care changes, review at termination of treatmentfacility, and approval for psychological testing prior to administrationensuring that quality care is provided in a safe environment;  Michigan licensure for psychiatric partial hospitalization for Outpatient Psychiatric Care facilities providing psychiatric day treatment,  Absence • Provider has an absence of inappropriate utilization or practices practice patterns, as identified through proven valid subscriber complaints, audits, audits and peer review, and,  Absence ; and • Provider has an absence of fraud and or illegal activities. Addendum C REIMBURSEMENT METHODOLOGY For each Covered Service performedServices performed that are within Provider’s scope of practice, BCBSM will pay Provider the lesser of the billed charges charge or the published maximum payment level per service, less any Deductible or Copayment for which the Member is responsible. The published maximum payment is set forth in BCBSM's published Outpatient Psychiatric Care Rate ’s Maximum Payment Schedule (Rate “Payment Schedule”). BCBSM will make the Payment Schedule available to Providers via web-DENIS. Most of the maximum payment levels are based on the Resource Based Relative Value Scale (RBRVS) system developed by the Centers for Medicare and Medicaid Services (CMS)Services, in which is a schedule of relative procedure values that reflect services are ranked according to the resource cost required costs needed to perform each serviceprovide them. The resource costs of the RBRVS system include physician time, training, skill, risk, procedure complexity, practice overhead and professional liability insurance costsinsurance. Values are assigned to each service in relation to the comparative value of all other services. The relative values are then multiplied by a BCBSM-BCBSM- specific conversion factor to determine overall payment levels. For procedure codes that have no CMS derived RBRVS value, BCBSM’s maximum payment level may be based on BCBSM’s medical consultants’ determination. Other factors that may be used in setting maximum payment levels include, but are not limited to, include comparison to similar services, corporate medical policy decisions, analysis of historical charge data and geographic anomalies. BCBSM may adjust maximum payment levels based on factors such as site of care or BCBSM payment policy. AdditionallyNationally imposed changes to the nomenclature and national coding system (HCPCS) for procedural codes, and corrections of typographical errors may result in immediate modifications to the maximum payment levels indicated Payment Schedule without prior notice. No other modification to the Payment Schedule will become effective until after 90 days have elapsed from the date of BCBSM’s notice to Providers. Notice may be provided either in written or electronic form. Written form shall include publication in the Record or other appropriate BCBSM provider publication. Electronic notice shall include, but not be limited to, publication on the Rate Schedule for each type of Professional Provider may vary, commensurate with the rendering provider’s level of licensureweb-DENIS. BCBSM will review Provider reimbursement levels periodically review Outpatient Psychiatric Care facility reimbursement to determine and may adjust them if BCBSM determines modifications are necessary. BCBSM does not warrant or guarantee that the review process will result in increased reimbursement. Addendum D SERVICES FOR WHICH PROVIDER MAY XXXX MEMBER Provider may xxxx Member for:

Qualification Standards. In order to participate with BCBSM under this Agreement, Provider must have and maintain all of the following Qualification Standards at each Approved Site:  At a minimum, a multidisciplinary staff consisting  Full accreditation in all components of a board-certified or board-eligible psychiatrist, a fully licensed psychologist, and a clinical licensed master’s social worker (CLMSW) with a master’s degree in social work;  A community governing or advisory board;  A comprehensive range of mental health services offered to the community including individual and group psychotherapy, family counseling, and psychological testing. Additional services required by patients and the community may also be included. Emergency services are available on a 24 hour basis through program staff or referral to other appropriate community agencies;  Proof of current licensure, registration, or certification at all times of Professional Providers on staff;  Accreditation ambulatory infusion therapy by at least one national accreditation organization approved by BCBSM, such as, but not limited to to, the following:  • The Joint Commission (TJC)) • The Accreditation Commission for Health Care (ACHC) • Community Health Accreditation Program (CHAP)  Direct employment,  Council unless otherwise indicated below, of a multi-disciplinary staff composed of the following: • A registered pharmacist, licensed in Michigan, to coordinate the patient’s pharmaceutical plan of care with the nurse, the medical director, and the patient’s physician or licensed health care practitioner. • An employed or subcontracted Michigan licensed physician medical director who has expertise in infusion therapy services, to provide overall direction for the clinical aspect of the ambulatory infusion therapy services delivered. • A registered nurse that will develop, coordinate, and supervise all activities of nursing services, including responsibility for assuring that only qualified individuals administer the intravenous drugs. The nurse will also consult with the pharmacist and the patient’s licensed health care practitioner to coordinate the patient’s care • A registered nurse or certified phlebotomist to draw blood samples for testing. • Registered nurses who provide patient care must have specialized education or training in infusion services. The provider may subcontract additional nursing services on Accreditation an as-needed basis if such registered nurses have specialized education or training in infusion therapy services.  Current Michigan pharmacy license.  Have in place documented program evaluation, utilization review and peer review processes to assess the appropriateness, adequacy and effectiveness of Services the program’s administrative and clinical components applicable to all patient services in accordance with the requirements of BCBSM and the appropriate accrediting and regulatory agencies.  Written policies and procedures that meet generally acceptable standards, as determined by BCBSM, for Families and Children (COA),  Commission on Accreditation of Rehabilitation Facilities (CARF), or  American Osteopathic Association (AOA);  Significant involvement by a psychiatrist on staff ambulatory infusion services to assure the quality of patient care, and demonstrate compliance with such policies and procedures.  Maintenance of a physical location on an appropriate site in Michigan, as determined by BCBSM, where the provider conducts business as a supplier of ambulatory infusion therapy.  A toll free emergency telephone number, available during business hours.  A system that ensures prompt delivery and appropriate storage of pharmaceuticals and medical supplies and dependable maintenance and servicing of infusion equipment.  A documented recall policy and procedure in the psychiatrist assumes overall responsibility for coordinating event of a Food and Drug Administration recall of an infusion product.  Maintenance of adequate patient and financial records.  Assurance that care is provided under the care of all patients. Significant involvement by a psychiatrist in an Outpatient Psychiatric Care facility includes, but is not limited to: approval general supervision of the initial evaluation, certification patient’s physician or licensed health care practitioner and follows a written and signed plan of the diagnosis, certification of the treatment plan, evaluation of client progress, intervention for medical reviews, intervention for level of care changes, review at termination of treatment, and approval for psychological testing prior to administration;  Michigan licensure for psychiatric partial hospitalization for Outpatient Psychiatric Care facilities providing psychiatric day treatment,  that meets BCBSM’s requirements. The treatment plan must be signed yearly.  Absence of inappropriate utilization or practices practice patterns, as identified through proven valid subscriber complaints, audits, and peer review, and,  and  Absence of fraud and or illegal activities. Addendum C REIMBURSEMENT METHODOLOGY For each Covered Service performed, BCBSM will pay Provider the lesser of billed charges or the maximum payment level set forth in BCBSM's published Outpatient Psychiatric Care Rate Schedule (Rate Schedule). Most maximum payment levels are based on the Resource Based Relative Value Scale (RBRVS) developed by the Centers Reimbursement for Medicare covered ambulatory infusion services includes two components: pharmaceuticals and Medicaid Services (CMS), which is a schedule of relative procedure values that reflect the resource cost required to perform each service. The resource costs of the RBRVS system include physician time, training, skill, risk, procedure complexity, practice overhead and professional liability insurance costs. Values are assigned to each service in relation to the comparative value of all other services. The relative values are then multiplied by a BCBSM-specific conversion factor to determine overall payment levels. For procedure codes that have no CMS derived RBRVS value, BCBSM’s maximum payment level may be based on BCBSM’s medical consultants’ determination. Other factors that may be used in setting maximum payment levels include, but are not limited to, comparison to similar services, corporate medical policy decisions, analysis of historical charge data and geographic anomalies. BCBSM may adjust maximum payment levels based on factors such as site of care or BCBSM payment policy. Additionally, the maximum payment levels indicated on the Rate Schedule for each type of Professional Provider may vary, commensurate with the rendering provider’s level of licensure. BCBSM will periodically review Outpatient Psychiatric Care facility reimbursement to determine if modifications are necessary. BCBSM does not warrant or guarantee that the review process will result in increased reimbursement. Addendum D SERVICES FOR WHICH PROVIDER MAY XXXX MEMBER Provider may xxxx Member for:administration.